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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CU�jTACT NAME <br /> A W/4 pe'2KlG(-r /i� AI&14/ D. <br /> C ADDRESS(Street address of TANK location) PHONE A (with area code) <br /> 1J 19 7 E /cE7 T��M9nJ Zo 3 r!-T_-o 1 z- <br /> I CITY STATE I ZIP CODE I NEAREST CROSS S7REEr <br /> T /,- D C It 47 <y 1/0 1 4 u <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if iafurmation different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P )=Akfics 0,j GcJ)avx=IZx��l7' <br /> E MAILING or <br /> A r�STREET ADDRESS OPERATOR PIIONE® (with area code) <br /> R c76x 3 z- 2 oq 33zy <br /> T CITY STATE I 'LIP CODE <br /> 0 � 6D / CA 25'�-`fr <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 OWN ERCONTACrNAME <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E 8 fi /�EirLEMif�✓ Za 3 3`t-2o i <br /> R CrN STA"rE I 'LIP 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 <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <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 SIM CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL.Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CUR111iffrLY EMPTY IF PEiMANFNT'LY CLOSED CWSUIW IN PLACE <br /> N <br /> I <br /> N <br /> F <br /> O <br /> TMS FORM COMPLIITED DER PENALTY OF PERJURY,AND T`O 71W BEST OF MY KNOWLEDGI.;IS TRUE ANO CORRECT. <br /> NAME ) / TITLE ©W AYE - DATE <br /> OFFICE SE&LY <br /> swum it I compo Loc CODE DISI'CODE YACHVE UGI' a ULEMPT'LKil- M CU.ISEU UG'1' SWEEPS PIIGM/SUO COUE UA'1'li <br /> EH 23 044(17/88) <br />