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*V/N JOACU14 CCUNTY PUBLIC HEALTH SERVICES O {' <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM ^ n� yT AI. <br /> FACILITY/SITE INFORMATION (Complete this Form for each faciiity/site) ENVIR� II VICES <br /> FARM or BUSINESS NAME i ONTACT NAME <br /> (PF� A) <br /> '1 DDRESS (Street address of TANK location) HONE # WITH AREA CODE <br /> 4 7 <br /> 4 IITYTATE IZiP CODE EAREST CR 55 STREET <br /> �/ t! <br /> HECK ARE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 8 ADDRESS (Complete if Information Different from Above) <br /> AME PERATOR CONTACT NAME <br /> AILING or STREET ADDRESS pPfERATOR PHONE # WITH AREA CODE <br /> 'M <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY CWNER INFORMATION 8 ADDRESS (Coaplete if Different frau Above) <br /> AME LINER CONTACT NAME <br /> AILING or STREET INFORMATION LINER PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CTIVFAM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> !!jE.RMAEEhTiLY <br /> XEMPFARMTANKSITE � (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFCRMATION (List Additional tank information on separate sheet if needed) <br /> TANK SIZE CHEMICALS STORED STIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AHE _ /� ITLE ATE <br /> OFFICE USE ONLY <br /> EEPS # CNP # I LOC CODE DIST CODE I # ACTIVE UNIT # EXPEMT UGT # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />