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Underground Stt.�,.ge Tank Program - Farm Tan.nformation Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAMECONTACTNAME A W- Ga. le. n G IOrICL, �1 . Johnson sa-rne- C ADDRESS(Street address of TANK location) PHONE# (with area code) I 1i � os Y1 . HU-) Lj 99 q 31 - 13 37 ICITY STATE ZIP CODE NEAREST CROSS STREET T � od1 Ca Rs� (: ? Mile- Rload_ Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) 0 NAMEn OPERATOR CONTACT NAME A P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A T CITY STATE I ZIP CODE O R CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) NAME i— OWNER CONTACT NAME O l� NMAILING or STREET ADDRESS OWNER PHONE#(with area code) E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX t,I. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) P F' x PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site moved r 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 OP REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE KOC, D ()eI-&C. l relnuvecL 9 - 11 - SS I see a:bt0_CkeA N remov F1 ermt THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF/MY KNOWLEDGE,IS TRUE AND CORRECT. NAME TITLE evivDATE ''/ S OFFICE USE ONLY SWEP.PS# COMP# LOC CODE I DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGM/SUB CODE RATE EH 23 044(12188)