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Underground Sto?Tge Tank Program - Farm TankInformation Form <br /> FACILITY/SITZ';INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME p CONTACTNAME <br /> A v ✓ ct 4C <br /> C ADDRESS(Street address of TAN location) -PHONE M (with area code) <br /> i 3 7 Pzc�cc l2c�P <br /> 1 Cl/1Y SPATE �ZZIP CODE NEAREST CROSS S T <br /> T htG cr Wt, ��C /S2 2& <br /> Y r--n—CHECRIERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> 0 NAME n OPERATOR CONTACT NAME <br /> P 1 11 <br /> E MAILING or STREET ADDRESS <br /> R OPERATOR PHONE N (with area code) <br /> A <br /> T CITY SiAIL LIP CODE <br /> 0 <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> tCITY <br /> // �/ OWNER CONTACT NAME <br /> t L v '7 CY 2 cze,6- <br /> MAILINGI ADDRESS n 2 El HONI�ap(with area cmc) <br /> UGr- LYi 'C OQ o—�L 7� <br /> STATE ZIP CODE <br /> � z�ERE if this ADDRFSS 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 <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SITE <br /> (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 ML77i00 OF CIDS URE DATE OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY Y OR PREVIOUSLY IF CUIUiPNFLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> Kms , <br /> I <br /> N <br /> F <br /> 0 <br /> T1US FOLtAt IIAS aEF.N CO UNDER PENALTY OF PERJURY,AND TO TRE a1ST OF MY KNOWLEDGE,LS TRUE AND CORRECT. <br /> N G .GG CY,6L / TITLE Yl a DATE <br /> 01I CE USE ONLY <br /> SWEEPS UDMPN LAC CODE DIST CODE NACI7VE IKiT MliXP1.11'1'UG'f -.!2—UG, <br /> SWEEPS PRGM/SUE CODE DATE <br /> M 23 044(12/88) <br />