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Underground Storage Tank Program - Farm Tank Information Form�� <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) ✓ Nk <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> C ADDRESS(Street address of TANK location) PHONE p (with area code) <br /> I <br /> L <br /> I i CITY STATE ZIP CODE I N"" ZEST CROSS S"IREE"I' <br /> T <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete If Information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE d (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> R 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 /> O <br /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERR if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacily) <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 IASL'USED MEn IOD OF CLAS URE DATE OF I(EMOVAL OI( <br /> A (GALLONS) CURRENTLY oR PREVLOUSLY IF CURILENMY EMPTY IF PERMANENTLY CLOSED CL)SURI.'IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> O <br /> TIUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERIURY,AND TO THE DIST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE DAIr, <br /> OFFICE Uilk ONLY <br /> SWEEPS Ep0 LAC CODE DISTCODEa ACTIVE WT 1 0WiMPT UGI' ICLClSED UG'1SWLLPS 1'l(GM/SUD CODE UA 1'1i <br /> EH 23 044(1 Z(88) <br />