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Underground St-rage Tank Program - Farm Tan's Information Form <br /> <. FACILITY/SITE 1NFORMATION"teomplete this form for each FARM TANK It;a -on.) <br /> F <br /> FARM or BUSINESS NAME CONTACT NAME <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> �zt9 -747 3 � 7 <br /> I CITY SATE 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 or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> TCITY STATE ZIP CODE <br /> O <br /> RI 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 STATEZIP 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 EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <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 /> K <br /> I <br /> N U Uot Cou+c /C CJYI Q izri s . <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMR6ETED UNDER PENALTY OF PERJURY,AND TO THE BIST OF MY KNOW LEDGE,IS TRUE AND CORRECT. <br /> NAME % c �(� TITLE fL�. E.7— DATE <br /> OFFICE USE ONLY i <br /> SWEEPS# COMP# IOC CODE I DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EJ 123 044(12188) <br />