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Underground St- ige Tank Program - Farm Tat Information Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A — i . i. C ADDRESS(Strut address of TANK location)` PHONE# (with area code) I .� q .S q--cs -.S L I CITY SPATE I ZIP CODE NEAREST CROSS STREET p C� ,J T Y CHtCK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) 0 NAME OPERATOR CONTACT NAME P �Mr ,J E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A T CITY A ZIP CODE 0 R CHECK HERE is this ADDRESS s ould be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) NAME OWNER CONTACT NAME 0 W MAILING or STREET ADDRESS OWNER PHONE#(with area code) N E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE.OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N I � ✓ - N F O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. NAME 1� - � TITLE ,�✓1 -- DATE OFFICE USE ONLY:' SWEEPS# I COMP# IOC CODE DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT I SWEEPS PRGMSUB CODE DATE i i r �} EH 23 044(12/88)