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UNDERGROUND VORAGE TANK PROGRAM - JARH TANK INFORMATION FORM <br /> FACILITY/BITE INFORMATION (Complete this For& for each FARM TANK location) <br /> FARM or BUSINESS WANE CONTACT NAME <br /> F J 10, 1 1r,ZaL z- h �� n1/gAJCP-lc - <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH ARCA CODA <br /> I <br /> T CITY l ST TE IIP CODE NEAREST CROSS STREET f <br /> Y J✓ J/v rY L� _J I' C� r� r1JVs- A) C� <br /> CNECA HERE if this ADDRESS should be used for Legal 'Notification <br /> OPERATOR IWORMATION A ADDRESS (Complete if Information Different from Above) <br /> WAKE OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH ARCA cool- <br /> R <br /> A <br /> I <br /> O Icily STATEF", <br /> CODE <br /> R <br /> CNEC1 MERE if this ADDRESS should he used for Legal Notification <br /> PRaPERrY owe INFORMATION L ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE i WITH ^RCA coag <br /> W <br /> N <br /> f. <br /> R CITY STATE IIP CODE <br /> CNECX ff fif if this ADDRESS should be used for Legal Notification <br /> Chec1 Appropriate Dox <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site R to or ( I,Joo gal. capacity) <br /> E <br /> 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 METHOD OF CLOSURE DATE Of REMOVAL OR <br /> Al (GALLONS) CURRENTLY OR PREVIOUSLY If CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K _ICA, i L 1 U e yL1 U U 44, <br /> I <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 DATE <br /> C�"LN /"--7 1 J <br /> OFFICE WE OW <br /> SWEEPS 1 COMP t LOC CODE DIST CODE 1 ACTIVE U61fl EXEMPT U6111 CLOSED UGT SWEEPS PRGM/SUD CODE DATE <br />