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Underground Storage Tank Program - Farm Tanilrinformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F For B SINESS AME CON A NAME <br /> A <br /> C A0kESS(Street address of TANK I i ) ONE# (with area code) <br /> I d! <br /> L <br /> I CI'T'Y/ STATE ZIP CODE NEAREST CROSS STREET <br /> T 410 � �cc.i &'�- 9 <br /> Y j I CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STR DRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> TLTY <br /> ZIP CODE <br /> O <br /> RCHECK HERt is this ADDRESS should be mod for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAMEOWNER CONTACT NAME <br /> O 64*A� <br /> NMAIL 1 G 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 /> .1. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ATI underground TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SITE (AL1.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 /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N r <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLI?TED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW LEDGE,IS TRUE AND CORRECT. <br /> NAME14A,l 14 <br /> TLE TE J <br /> OFFICE ONLY / <br /> SWEEPS# I COMP# LOC CODE I DIST CODE#ACTIVE Lxvr #FJLEMPTUGT #CLOSEDUGT I SWEEPSPRGMLSUBCODE DATE <br /> EH 23 044(IZW) <br />