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JJnder ground Sto*e Tank Program - Farm Tanaformation Form FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A C ADDRESS(Street address of TANK location) PHONE# (with area code) I L I CITY STATE ZIP CODE NEAREST CROSS STREET T Y I I CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) 0 NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A T CITY STATE I ZIP CODE 0 IRI I CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) 3��_4 95 NAME OWNER CONTACT NAME 0 LQGSA �n NG MAILINor STREET ADDRESS OWNER PHONE#(with area code) E L) R CITY STATE I ZIP CODE SdLla CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX .l. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y F EXEMPT FARM TANK SITE (ALL underground"TANKS at site = to or < 1,100 gallon capacity) E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OMOV OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE LACE N K - -d I N F O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME TITLE DATE _ O OFFICE USE ONLY SWEEPS# COMP# IAC CODE DISI'CODE#ACTIVE UGT I #EXEMPT UGT #CLOSED UGT I SWEEPS PRGM/SUBCODE DATE EH 23 044(12/88)