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Underground Stt"ge Tank Program - Farm Tan reformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F fARMr SIN SHAME CONTACT NAME / <br /> A / '� 6'1-1117 Co <br /> C AD RESS(Street ad ress of TANK location) IVF- PHONE# (with area code) <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T rc to� X p $IU <br /> Y CHECK 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 /> / — <br /> E MAiLING or smi Er ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE 'LIP CODE J <br /> R I I 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 /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> ati <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T 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 acit <br /> F' 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 EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME "TITLE -.e � 2L. DATE ' <br /> OFFICE,US ON <br /> SWEEPS M COMP# LOC CODE DIST CODE#ACTI V E UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />