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Underground Storm Tank Program - Farm Tank, formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACTNAME <br /> A J a Ekj iErj P, — E A >✓ 7 - 54—� <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> Lf- 8S1F <br /> L <br /> I CITY STATE ZIP CODENEAREST CROSS STREET <br /> T /t f A A/ CCU 533 6 O C 1-4 Al' �/Z <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 D M OPERATOR CONTACT NAME <br /> P f9cII <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> A AUG 14198 <br /> T CI'T'Y STATE 71P CODE <br /> ENVIR NMENTAL HE LTH <br /> O PE MIT/SERVICE <br /> R CHECK HERE is this ADDRESS should he used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> o A nlC us (� . M ` �/� SPC 311-r-' <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E 2 <br /> R CITY STATE ZIP CODE <br /> M A r i -ra-c-A COU q5-3-3G <br /> r-TC-11ECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,l, 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 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 STOKED ESTIMATED DATE LAST USED METHODOFCLO.SURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 0t- i,,V b 9117-71"1 <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE.REST OF MY KNOW LEDGE,IS TRUE AND CORRECT. <br /> NAME "CITLB DATE y <br /> OFFICE USE P&LY <br /> SWEEPS# COMP# LOC CODE I DIST CODE#ACTIVE UGT I #ExEMPT UGT #CLOSED UGT I SWEEPS PRGMr.UB CODE I DATE <br /> EH 23 044(12J88) <br />