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Underground Stor,..de Tank Program - Farm Tank formation Form <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A � .9 <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> / AP, <br /> I CI STATE I ZIP CODE I NEAREST CROSS STREET <br /> Y CHE 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 P?j a code) <br /> R I15� <br /> A <br /> •I• CITY STATE I ZIP CODE <br /> 0 51989 <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above jERMS!""ICES <br /> NAME OWNER CONTACT NAME <br /> O <br /> N MAILING 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 /> ,I• 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 cil <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALI,underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if needed.) <br /> T TANKSIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATEOF REMOVALOR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 00 <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO T11E BEST OF MY KNOWLEDGE,IS TRUE AND CqRRECT. <br /> 6 <br /> TITLE DA <br /> OFFICE.USE ONLY <br /> SWEEPS N I COMP# I LOC CODE DIST CODEJ#ACTIVE WT #EXEMPT UGT #CLOSED UGT SWEEPS PROM/SUB CODE DATE <br /> EH 23 044(1ZIR <br />