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Underground Stc ge Tank Program - Farm Tan. .nformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME <br /> \\ CONTACTNAME <br /> A j ' ltd S (Jr� r / amivYl Joh /1 n? 11elides <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I <br /> L 90>- 893 - 7L1.?3 <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T l- fl ( Gl ldO � G�-7 �i633� <br /> Y v 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 or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A _�... <br /> T CITY STATE <br /> 0 <br /> JR1 I CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME i OWNER CONTb:CT; 1SERVI <br /> J C; <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area cafe) <br /> E / Crom 5f <br /> R CITY STATE I ZIP CODE <br /> 5 336 <br /> �*J'4ecr., <br /> ECK 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 ( g g capacity) <br /> P ALL underground TANKS at site = to or < 1,100 gallon ea acit <br /> E t, 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 /77 <br /> K �)-.nOO C r/sol)Ot/ /'T SS l�emovecl 7 �b l�1y <br /> I <br /> N <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 <br /> OCGV) ) G//� TITLE �y t DATE �)-3/ S'�/ <br /> OFFICE US* NLY <br /> SWEEPS# COMP# LOC CODE I DIST CODE#ACTIVE UGT I#EXEMPTUGT #CIOSEDUGT I SWEEPS PRGMISUHCODE DATE <br /> EH 23 044(12/88) <br />