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Underground St"tge Tank Program - Farm Tai.,Information Form <br /> '1 �FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.091k <br /> F FARM or BUSINESS NAME - CONTAC"T NAME 1 1989 <br /> A 3 L _"E ;1 <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) _ <br /> L <br /> I C17y STATE ZIP CODE NEAREST CROSS STREET <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 OPERATOR CONTACT NAME <br /> P �. <br /> E MAILING of EET ADDRESS OPERATOR PHONE# (with area code) <br /> R i <br /> "I. CITY -/— STATE Z[P CODE <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 OWN ER CONTACT NAME <br /> O <br /> L C, <br /> W <br /> MAILING or STREET ADDRESS v OWNER PHONE#(with area code) <br /> N <br /> R CITYQ 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 <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E � PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> v <br /> UNDERGROUND TANK INFORMATION (List additional tank Information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED MLTHODOFCLOSIIRE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THti BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE " !) a DATF" <br /> OFFICE U. EIONLY 1 � <br /> SWEEPS# COMPM I LOC CODE DIST CODE #ACTIVE UGC #EXEMPTUGT #CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> Eli 23 044(12/88) <br />