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Underground Ste �ge Tank Program - Farm Tan' information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F F Qo�rI NA1'ME CONTACTNAME <br /> C ADDRESS(Street address of TANK location) _ PHONE# (with area code) <br /> L oqo4s 4 62 il ri-;73 <br /> I Cf/�Y N�� SSTATF ZIP CODE NEAREST CROS EEr r <br /> T f714)p lfl (f o <br /> Y ICHECK 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 <br /> E MAILING or STREET ADDRESS OPERATOR PHALW(i3t(Ni:aW 4We) <br /> R I?ECEIVEC <br /> A <br /> T CITY STATE I ZIP CODE <br /> 0 <br /> JR1 I CHECK HERE is this ADDRESS should be used for Legal Notification. WV ONM6 <br /> UIT cc-„ I, <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) Fti <br /> N 0 R CONTACT NAME <br /> o eT1?A16-_&1kC111 <br /> WNG or STRE ADDRESS i O ER PHONE#(with area code) <br /> N v2- oZS— <br /> E <br /> R CITY S ZIP CODE <br /> e ir.� 9s2x <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .I. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <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 CLJDSURE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> 0 <br /> TINS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME ` TITLE '/fy� DA p� <br /> OFFICE R§E ONLY <br /> rEN COMP# LOCCODT1STCKDEj#ACT1VEUGT #EXEMPT UGT #CLOSEDUGT I SWEEPS PRGM/SUBCODE DATE <br /> EH 23 044(17/88) <br /> (aeeKC� C�-ILA-C6�) <br />