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Underground StL.tge Tank Program - Farm Tar-`[nformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME _ CONTACT NAME <br /> A I)QULC1 1 r Arms Q1? t Ded/1) <br /> C ADDRESS(Street address of TANK location) PHONE N (with area code) <br /> L /(/yd5 4�l/nta Sd_ � 91'3ISD <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T �Ipof) c A 9s,36( `r1. k1 i >ti <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAME. OPERATOR CONTACT NAME <br /> P rr tai <br /> E MAILING or STREET ADDRESS OPERATOR PHONE k (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> RI CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME _ OWNER CONTACT NAME <br /> NMAILING or STREET ADDRESS OWNER PHONE R(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ACTIVE FARM TANK SITE �uC'(OnAq <br /> T A'bGnCl qQ�. / trbr more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g 6 capacity) <br /> F ALL underground TANKS at site = to or < 1,100 gallon ca acit <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K C(iffc l a c r• 0 <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE DATF.%I <br /> OFFICE USE ONLVY <br /> SWEEPS N I COMP M LOC CODE I DIST CODE N ACTIVE UGT I M EXEMPT UGT N CLOSED UGT I SWEEPS PRGMSUB CODE DATE <br /> and Dialyj 13,;Z6, I 1 2 O a <br /> EH 23 044(12/88) <br />