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Underground Stor'lge Tank Program - Farm Tank-Thformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAKE CONTACT NAME <br /> A 4 <br /> C ADDRESS(Street address of TANK location) PHONE# (with area codc) <br /> I i j �, <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T <br /> Y C CK HERE if this ADDRESS should he used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P � t ( <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <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 CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNIPIIO #(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 /> ,l, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g B capacity) <br /> P ALL underground TANKS at site = to or < 1,100 gallon ca cit <br /> E x 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 TANKSIZE CHEMICALS STORED ESTIMATED DATE LASTUSED METHODOF CLOSURE DATE OF REMOVAL OR <br /> A (GAL IONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K C j) <br /> N 6/AJ <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 - — l , r �-� F' <br /> DATF <br /> OFFICE USE ONLY <br /> SWEFN# COMP# I LOC CODE DISC CODE N ACTIVE IKiT #EXEMPT UGI' #CLOSED U(Y SWEEPSPRGMISUB CODE DATE <br /> EH 23 044(12/88) <br />