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Underground Sto*Ye Tank Program - Farm Tani6formation 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 STATE I ZIP CODE I NEAREST CROSS STREET <br /> T <br /> Y LICHECK 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 It (with arca code) <br /> R <br /> A <br /> T CITY STATE ZIP CODE <br /> O <br /> RI 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 /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> R CITY STATE I ZIP CODE <br /> /�? C 4 %,j_Ly C,. <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 t PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> A — <br /> UNDERGROUND TANK INFORMATION(List additional tank inforniaLion 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 IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HA6 BEEN COMPL737ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> NAMEc-'4 .--L, T[TLE <br /> — DATE ,f`_ f' <br /> OFFICE USE ONLY <br /> SWEEPS# I OOMP# LOC CODE DIST CODE#ACTIVE UGT I#EXEMPTUGT #CLOSEDUGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />