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U-D•RGROUNO STOR66E 16NK PRQUa A - ,[AggThNINFOggdjlAN FORM <br /> FACILITY/SITE INFORMATION (Coaplets this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F 7J5M �mr-,� <br /> A D6 lid 5. Ile <br /> C ADDRESS (Street address of TANK location) PHONE I WITH ANSA 0009 <br /> L �98� �. 6 rel lZd Q9 — 35 <br /> I <br /> T CITY STATE tIP CODE NEAREST CROSS STREET <br /> Y oq!,` LP, �S Llko <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Coaplete if Inforaation Different frog Above) <br /> NAME OPERATOR CONTACT NAME <br /> O <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH ANSA CODE <br /> R <br /> A <br /> T <br /> 0 CITYSPATE IIP COBE <br /> R <br /> CHECK NEAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Coaplets if Different froa Above) <br /> NAME OWNER CONTACT NAME <br /> O MAILING or STREET ADDRESS OWNER PHONE I WITH ,.44A CODE <br /> N E old —33*—to e 3..r— <br /> R CITY STATE 1IP CODE <br /> Lo�C, 144t2. <br /> CHECK HERE if this ADDRESS should he used for Legal Notification <br /> Chee1 Ipproprlate Box <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,140 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site v to or ( 11104 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 BATE 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 <br /> K Sp© 5 L)I'& nV k"w)d 1;�&K 3 Biu I <br /> I <br /> N <br /> F <br /> 0- <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT <br /> NAME TITLE DATE <br /> file/ d w 7tt"-- rvo r Z� zaa <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE I ACTIVE UGf I EXEMPT UGT I CLOSED UGi SWEEPS PREM/SUB CODE BATE <br />