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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 CONTACT NAME <br /> A <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I <br /> L <br /> I CITY ';'M E ZIP CODE NEAREST CROSS STREET <br /> T <br /> Y CHECK HERE if this ADDRESS should he used for Legal Notification <br /> OPERATOR INFORMATION &ADDRF^omplete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R — - - — <br /> A <br /> T CITY SPATE ODE <br /> O <br /> 1111 1 CHECK HERE is this ADDRESS s Id be ujrfor Migal Notification. <br /> PROPERTY OWNER INFORMATION S (Co tete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> O <br /> NMAILING or STREETDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY ST E ZIP CODE <br /> CK HERE if thijkDDRESS should sed for Legal Notifies(' <br /> CIIECK RO TE BOX z <br /> .1, A VE F ANK S ne or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EX X <br /> FARM T (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMIENTLY CLOSED F!T#J111k&NK SIT (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND At INFORMATION(List add' ual tank Information on separate sheet if needed.) <br /> T TANK SIZE ICALS STORED1MATFD DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) C Y OR PREVIOUSLY , IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <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 /> OFFICE USE ONI.Y <br /> SWEEPS# COMP# LOC CODIi I DISI CODF,#ACTIVE UGT I#EXEMPT UGT #CLOSED uar I swLiuS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />