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Underground Storage Tank Program - farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or B//USINESS�,1AMB CON•rACf NAME <br /> A CJS I' / 7. C'T� <br /> C ADDRESS(SI ad of TANK location) I'IIONE# (with area cafe) <br /> �i <br /> I D _� _ " C/< l 27&-- <br /> L I fY �14TE ZIP CODE NEAREST CROSS STR f <br /> I C 1 0 <br /> T 7/%�7"7�f'P<� Gjs�3� N� /dv �- <br /> �'C <br /> Y / I CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if Information different from rbove) <br /> 0 <br /> NAME 011FRATOR CON'IACf NAME'. <br /> P <br /> E MAILING or STREET ADDRESS OPERAT�IONE (with area talc) <br /> R <br /> A <br /> T CITY STATE LIP COUE <br /> 0 <br /> RCHECK 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 /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> •1, 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 /> UNDERGROUND TANK INFORMATION (List additional tank Information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALS STORIED ESTIMATED DATE LAST'USI;D MEINOD OF Ct.OSURF1 DATE 01:REMO VAT.Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IP CURREM'LY EMP'T'Y IP PERMANWILY CLOSED CLO.SURIi IN PIAC'E <br /> N <br /> K _ oao �/(� <br /> v I ;Z COC <br /> 9 ��- <br /> N <br /> F <br /> O <br /> 1 1 <br /> TITIS FORM HMBEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TI@:BEST OF MY KNO W LEDG�IS TRUE AND CORRNCr. <br /> NAME II'fLE DATE ITE=7- <br /> OFFICE <br /> OFFICE USE ONLY <br /> SWLUTS# COMP# L.00CODE D1S7'CODE #ACIIVIitXi"1' #UCEiMPI'UG'I' NCLUSEUUE SWI:EI'SPIIGhUSUUCODI'I UA 11; <br /> NH TA full 1`0/BRl <br />