Laserfiche WebLink
Underground Storage Tank Program - Farm Tank`rnformation Form <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NI CONTACT NAME <br /> F1 49 O / <br /> C ADDRESS(Street pddressTANK tion) PHONE# (with area code) <br /> I C/D <br /> L ` <br /> I CITY S ATE I 'LIP CODE I NEAREST CROSS STREET <br /> T C C/4 2d <br /> Y CHECK HER If this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> o <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> TCITY 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 /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CI IECK APPROPRIATE BOX <br /> .I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( B gallon capacity) <br /> P ALL underground TANKS at site = to or < 1,100 llon ca cit <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 /> KMV <br /> I <br /> N <br /> F <br /> O <br /> TIDS FORM HAS=COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> NAME TITLE DATE <br /> OFFICE USE ONLY <br /> SWEEPS# OOMP# LOC CODE DIST CODE#ACTIVE UGT I#IiXEMPTU(Vr #CLOSEDUGT I SWEEPS PRGMISUB CODE DATE <br /> EH 23 044(12/83) <br />