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Underground Stec Tank Program - farm ThOnformation form <br /> RXCILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A ,/ ch Qdtli 0 H 0S(-- <br /> C ADDRESS(Street address of TANK location) PHONE N (with arca code) <br /> IG <br /> L L <br /> I CITY , STATE 7.IP CODE NEAREST CROSS STREET <br /> T / <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 NWE <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR Pl ONE N (with arca code) <br /> A <br /> T CITY STATE 'LIP CODE <br /> ° � <�' 56 <br /> 3 . <br /> R CFIF,CK HERR.is this ADDRESS should he used for Legal Notification. <br /> PI ,0PERTY OWNER INFORMATION &ADDRESS (Complete If different from above.) <br /> NAME OWNER CONTACT NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE M(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHUCK I IERP,if this ADDRESS should be used for Legal Notification <br /> CIIECK API'ROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXENIPT Flultvl TANK SITE (ALL underground TANKS at site = to or c 1,100 gallon capacity) <br /> R 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 Cl[INICALS STORED ESTIMATED DATE LAST USED MEIIIOD OF CLOSURB DATE OF REMOVAL_Olt <br /> A (GALLONS) CURRIMLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANFN LY CLOSED CLOSURE IN PLACE <br /> N <br /> K e ►� v ti1Z r'- /� ( 'A/ <br /> N <br /> F <br /> O <br /> TMS FORM L 11 EN COMPLETED UNDER PENALTY OF PERJURY,AND TO 711E BEST OF MY KNOWLEDGE,IS TRUE ANA CORRECT. <br /> A <br /> TITLE t <br /> NAME �, L �.;' ��� DATE <br /> OFFICE.USI;ONLY <br /> SW LI'-n N COMP M IAC:CODL' LIST'CODE M ACIIVE t1G'I' N EXBMPI'UGI' M CI.WE-D UGI' SWEEPS PIIGM/SUB CODRi DAPI, <br /> EH 23 044(12188) <br />