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Underground Sto. ge Tank Program - Farm Tan,.__nformation Form <br /> FACILITY/SITZ:INFORMATION (Complete this form for each FARM TANK location.) O <br /> F FARM or BUSINESS NAME CONTACT NAME ✓ <br /> A Jaz _ <br /> C ADDRESS(Strut address of TANK location) PHONE# (with area code) <br /> I CITY SLATE ZIP CODE NEAREST CROSS STREET <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 /> 0 NAME OPERA'T'OR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with arca code) <br /> R <br /> A <br /> T CITY STATE ZIP CODE <br /> 0 <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 CONTACTNAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHUCK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK 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 If needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METIIOD OF CLOSURE DATE OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IP CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K FJ kftj— U 1-,—w rZ, <br /> N4 <br /> F <br /> 0 <br /> THIS FORM IIA.S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> NAME TITLE DATE <br /> OFFICE USE ONLY <br /> SWEFPSN I WMPN UA:CODl3 DISTCADE #ACITVLUGl I NECEMPTUGI' NCLwr.DUGT SWfaPSPRGM/SUBCODE DATE <br /> Eli 23 044(17/88) <br />