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Underground Stora-Tank Program - Farm Tank flormation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A OP N /��I - (.1 'F c Jo) I`) V/Fly I <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I 2,� 0 0/✓C TtQEF CoA& -20q 9-77 - 7Vel) l <br /> L <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T I F S �h' � ci✓ c,4 , %S3�0 SCxTO�/ <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete 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 p <br /> A <br /> T CITY STATE I ZIP CODE o <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. �98 <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from ab6tw,,T ,SFr': ' gLIH <br /> NAME OWNER CONTACT NAME <br /> O <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,I, 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 Z. 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 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 p <br /> K Soo Ric-u�,/a , (- - � - , �Ma (/ tf S- /o <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAMP. TITLE / DATE <br /> OFFIC E ONLY <br /> SWEEPS# COMP# IAC CODE DISI'CODE #ACTIVEUG'f #E.XEMPTUGT #CLOSEDUGT SWG1iPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />