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Underground Stc.ge Tank Program - Farm Tan; aformation Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A C ADDRESS(Sheet address of TANK location) PHONE# (with area code) I1 L 15722 /l/Ly E I CITY �'STATEI ZIPCODE NEAREST CROSS STREET T 5-f oG 0AG1's1 Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) 0 NAME OPERATOR CONTACT NAME P Fy -1 m r E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R ; ! ! l"fit A T CITY STATE ZIP CODE R CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) NAME OWNER CONTACT NAME 0 NMAILING or STREET ADDRESS OWNER PHONE#(with area code) E R CITY STATE ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y p EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet If needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE. DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K ` I N F O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME ,_a. TITLE DATE OFFICE.USE ONLY SWEEPS# COMP# LOC CODE DIST CODE #ACTIVE UGT I #EXEMPTUGT #CLOSEDUGT SWEEPS PROM/SUB CODE DATE 1 EH 23 044(12/88)