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Underground Sage Tank Program - Farm TaWnformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> C ADDRESS(Street address of TANK location) PHONE N (with area code) <br /> I <br /> L <br /> I CITY Sl'ATB 'LIP CODE NEAREST CROSS STREET <br /> T <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERAI'OR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE s (with area code) <br /> R <br /> TCITY STATE I ZIP CODE <br /> O <br /> R CHECK It ERE 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 /> O <br /> W MAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <br /> E 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 /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TILE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE DATE <br /> OFFICE USE ONLY <br /> SW Ef:PS N COMP 0 1 LOC CODE DIS,r CODE N ACI'IVE Lur 0 EXEMPT UGT 0 CLOSED UGI' SWEEPS PRGMSUB CODE DATE <br /> Eli 23 044(12188) <br />