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Underground Stora OTank Program - Farm Tank In ormation Form <br /> FACILITY1131TE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> p <br /> C ADDRESS(Street address of TANK location) PHONE N (with area tale) <br /> I CITY STATE I ZIP CODEJ NEAREST CROSS STREET <br /> T �q <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 OPERATORCONTACrNAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE N (with arca 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 CONI'ACrNAME <br /> O <br /> NMAILING or STREETADDRESS OWNER PHONE N(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 /> ,1. ACnVE 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 moved r closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional tank Information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALS STORED FSTIMATGD DATE LAST USED METHOD OF CLOSURE DATE OFGM VAI OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLrYiED CLOSURI:IN PL ACE- <br /> N <br /> K '(-:170 <br /> N <br /> F <br /> O <br /> THIS FORM HAS BM64 C2!!!LVM UNDER PENALTY OF PERJURY,AND TO TIIE BEST OF MY KNOW LEDGE,IS TRUE AND CORRECT. <br /> NAME ��, TITLE ✓N�? — >�G DATE V g <br /> OFFICE USE 0 LY <br /> SW[iEPSY <br /> MP It LOCCODL'I DISTCODENACIIVE UOT I ItIXEMPTUGT itCI-WL:L)UGISWI1iMPRGM/SUUC0UE UA'I'li <br /> EH 23 044(12I88) <br />