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Underground Stoo Tank Program - Farm Tanoormation Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or 13USINBS NAME CONTACT NAME A C ADDRESS(Street address of TANK location) PHONE N (with area code) I L I CITY STATE ZIP CODE I NEARESTCROSS Y CIIECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete If Informatlon different from above.) O Nom' OPERATOR CONTACT NAME P E MAIUNG or STREET ADDRESS OPERATOR PHONE M (with area code) R A T CITY STATE 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 OWNER CONTACT NAME ° MAR,t 4 -TR A 57G/z NMAIUNG or STREET ADDRESS OWNER PHONE N(with area code) E i. R CITY STATE ZIP CODE (�SLAL_0A �` 15-3z, CHECK HERD,if this ADDRESS should be used for Legal Notification CIIECK APPROPRIATE BOX .1. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) E PUMANENTLY CLOSED FiUtM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDIOtGROUND TANK INFORMATION (List additional tank Information on separate sheet If needed.) T TANK SIZE CIIHMICALS SIORE'D ESTIMATT.D DATE I-AST USED mr,n ioD OF CLOSURE DATE OF REMOVAL Olt A (GALLONS) CURRLMLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K I N F 0 THIS FORM HA.S IIEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TIRE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. NAME <zVHt TITLE DATE 771 OFFICE.USE ONLY S W EI•J'S N WMP N LOC CODL DIST CODE N ACHVE UG'f N MEMPI'UGI' N CLOSED UGT SWEEPS PRGM/SUD CODE DATH Ili 23 044(12/88)