Laserfiche WebLink
1 , <br /> Underground Stora?e Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or EUSINE5, CONTACT NAME <br /> A `� <br /> C ADDRESS(Street address of TANK location) PHONE p (with area code) <br /> I /,;� 700 . a��Zc�ae; l�t� ao1 Bo? 3-- �, 'JY-5� <br /> L <br /> I CITY STATE I ZIP CODE NEAREST CROSS ST1tECf t--,' 'c'�� <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 OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PIIONE k (with area code) <br /> R <br /> A <br /> TCITY 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 CONTACT NAME <br /> NMAILING or STREET ADDRESS OWNER PHONE It(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 /> .I, f ACnVE FARM TA14K SITE, (Oce 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 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 MEMOD OF CLOSURE DA'Z'E OF REMO VA!-Olt <br /> A (OALLONS) CURRENTLY OR PREVIOUSLY IF CURREMILY EMPTY IF PERMANENTLY CLOSED CLOSUIU;IN PLACE <br /> N <br /> K ooh' , <br /> I /o DU / 7,g r➢�/ i. X � <br /> N <br /> F <br /> O <br /> THUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE.AND CORRECT. <br /> N — z^a d c TITLE C��'�C DAW 9 �) <br /> OFFICE USE ONLY <br /> SWEEPS YCOMPM L.00 CODE DISI'CODEMACIIVEU(i'1' aEXEMPI'UG'I' MCWSEU UG'1' SWEETS PRGM/SUU CUUE UA'I'IS <br /> 112188 <br /> 1 <br />