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Underground Sto..,;e Tank Program - Farm Tani,>formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A � 2i T IV16 4 S72FVzf-/I/ /(/iekt� <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> � ,5& 3 / �ttz-Em H/V - 36,r-QS-Zq <br /> I CITY <br /> STATE ZIP CODE I NEAREST CROSS STREET <br /> T /-o ✓J C/l �t�S-1O Q8j---M /W xf 61X e <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 /> A <br /> T CITY STATE I ZIP CODE -- <br /> O <br /> R 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 /> 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 /> .T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g gallon capacity) <br /> P ALL underground TANKS at site = to or < 1,100 llon ca acit <br /> E X PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at sit remov r 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 INPLACE <br /> K `3W �r►is D(Fsr 02 — <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE DATE ��— <br /> OFFICIIKUSE ONLY <br /> SWEEPS# (AMP# LOC CODE DIST CODE#ACTIVE UGUT I#EXEMPT UGT #CIOSED UGT SWEEPS PRGMISUB CODE DATE <br /> EH 23 044(12/88) <br />