Laserfiche WebLink
Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) , <br /> F FARM or USINES CONTACI'NAME <br /> A <br /> C ADDR S(Street s dreu of T Incati n) PI-IONE A (with arca code) <br /> L � 6j j -3 — z <br /> I CITY TE IP CODE NEARIST CROSS S �1 <br /> TtE ' n <br /> T �s LI5— 34e <br /> YI CH CK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete it InfornLation different Crow ubove.) <br /> 0 NAME OPERATOR CONTACT'NAME <br /> P <br /> E MAILING or STREET ADDRESS s {E$1 wj fell code) <br /> R <br /> A <br /> OCITY STATE I 'LIP CGDE AUG 2 91989 <br /> RCHECK HERE is this ADDRESS should be used for Legal Notification, <br /> B E(vViR0PdIv1ENTAL HEALTH <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWN ISH CONTACT NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <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 /> .r. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> PEXEMPT 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 ESTIMA11iD DATE LAST USED METHOD OF CLOSURE DA'Z'E OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURREPfILY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE. <br /> N <br /> K <br /> c <br /> I t Gli <br /> N <br /> F <br /> O <br /> TIUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TILE DFST OF MY KNOWLEDGE,IS TRUE AND CORRI.-Cr. <br /> NAME TITLE DA1ti <br /> OFFICE USE ONLY <br /> SWEFJPSM 1 C F LUC CODLLS'I'C.ODEM ACTIVE LKT 1 0LiXEMPT UGI' 10 CLOSED UGISWIiliPS PIiGMISUU CODE Un EI- <br /> T-1411 <br /> iFH11 WJ 09/0.81 <br />