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Underground Storage Tank Program - Farm Tank Information Form <br />FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br />F <br />FARM or BUSINESS NAME <br />OPERATOR CONTACI' NAME <br />CON'PACf NAME _ _ <br />A <br />s" <br />P <br />/, <br />C <br />ADDRESS (Street address of TANK lorA top) <br />MAILING or STREEI'ADDRESS <br />PHONE N (with area code) <br />R <br />/ <br />R <br />! <br />CITY <br />FSTATE <br />I ZIP CO/DjE <br />NEAR <br />ROS' S1REF1' <br />T <br />�l�J <br />�% <br />f <br />�l <br />R <br />CHECK HERE is this ADDRESS should be used for Legal Notification. <br />Ihd <br />L">�C <br />Y <br />I CHECK HERE if this ADDRESS should be used for Legal Not ificalion <br />OPERATOR INFORMATION & ADDRESS (Complete If Information different from above.) <br />PROPERTY OWNER INFORMATION & ADDRESS (Complete if different from above.) <br />NAME <br />OPERATOR CONTACI' NAME <br />0 <br />METHOD OF CLOSURE <br />OA'I L OF REMOVAL OR <br />P <br />or STREET ADDRESS <br />OWNER PIIONEH(witharca code) <br />E <br />MAILING or STREEI'ADDRESS <br />OPERATOR PHONE N (wish area code) <br />R <br />R <br />CITY SfA"11: <br />"LIP CODE <br />A <br />T <br />Cff'Y <br />STATE <br />I 711CODE' <br />0 <br />K <br />R <br />CHECK HERE is this ADDRESS should be used for Legal Notification. <br />PROPERTY OWNER INFORMATION & ADDRESS (Complete if different from above.) <br />CfIECK APPROPRIATE BOX <br />.I. <br />NAME <br />OWNER CONTACT'NAME <br />O <br />METHOD OF CLOSURE <br />OA'I L OF REMOVAL OR <br />NMAILING <br />or STREET ADDRESS <br />OWNER PIIONEH(witharca code) <br />E <br />IF PERMANENTLY CLOSED <br />PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br />E <br />R <br />CITY SfA"11: <br />"LIP CODE <br />N <br />CHECK HERE if this ADDRESS should be used for Legal Notification <br />CfIECK APPROPRIATE BOX <br />.I. <br />TANK SIZE <br />ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br />Y <br />METHOD OF CLOSURE <br />OA'I L OF REMOVAL OR <br />P <br />(GALLONS) <br />EXEMPT FARM TAI4K SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br />E <br />IF PERMANENTLY CLOSED <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 <br />TANK SIZE <br />CHEMICALS STORED <br />ESI'IMA`ILD DATE LAST USED <br />METHOD OF CLOSURE <br />OA'I L OF REMOVAL OR <br />A <br />(GALLONS) <br />CURRENTLY OR PREVIOUSLY <br />IF CURRENTLY EMPTY <br />IF PERMANENTLY CLOSED <br />CLOSUIUi IN PIACI. <br />N <br />K <br />Ihd <br />U LJ <br />F <br />0 <br />TIIIS FORM HAS BEEN COMPLMXD UNDER,PENAILI'Y OF PERJURY, AND TO"IE RE4'r OF MY KNOWLEDGE, IS TRUE AND CORIU%CT. <br />NAME A/177- DATE <br />OFFICE USE ONLY <br />SWEETS MMPN IAC CODLULSTCODE N ACIIVEUG"I' NFXEMPI'UGI' oCLOSED UG'I Swlilil'5 mwwsUD CODE DAL <br />FA 23 044 (12/881 <br />