Laserfiche WebLink
/. Underground Sto_;e Tank Program - Farm Tan? .1formation Form <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME <br /> ", : CONTACT NAME <br /> A `gid i ( <br /> C ADDRESS(Street address ofTANK Itio <br /> I ) <br /> ) PHONE,# (with area code) <br /> L ( L <br /> I CITY f ST TE ZIP CODE NEAREST CROSS STREET <br /> T — I <br /> Y CHECK ERE 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 <br /> R OPERATOR PHONE# (with area tale) <br /> A <br /> T CITY STATE I ZIP CODE <br /> 0 <br /> R CHECK HERE is this ADDRESS should he used for Legal Notification. <br /> PROPERTY OWNER INFORMATION Sr ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> O <br /> N co <br /> MAILING or STREET ADDRESS OWNER PHONE#(with area de) <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 /> .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 U 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 114d PLACE <br /> R <br /> S M 09 A ?C ¢ d <br /> I <br /> �0 <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE (^(r. f, (- / - DATE <br /> OFFICE USE ONLY <br /> SWEEPS COMP# I LOC CODEJ DISTCODE#ACTIVE UGT #EXEMPT UGT J#CLOSED UGT I SWEEPS PRGM)SUB CODE DATE <br /> EH 23 044(12/88) <br />