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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FAI�r BUSINESS N CON"QCT NAME <br /> F i / ? JQ e'l, <br /> A <br /> C ADDRESS(Street address of TANK 1 "tion) PHON (with arca cafe) <br /> IZ � �• )f� . . � 0 <br /> 12 4, � j/ � 22 Y0 <br /> L <br /> I CITY SATE ZIPCODE NEAREST ut SS STREET <br /> T ( c�1 1k ai Ct1e /5 3 �� <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 CON'rACI'NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE N (with area code) <br /> R <br /> ,AI. CITY STATE I ZIP CODE <br /> O <br /> RCHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACC NAME <br /> O <br /> NMAILING or STRFfr ADDRESS OWNER PHONE N(with area este) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> (ALL underground'fANKS at site = to or < 1,100 gallon capacity) <br /> P EXEMPT FARM TANK SITE <br /> E <br /> 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 TANKSIZE CHEMICALS STORM ESTIMATED DATE L1.S1'US111) MEITiOD OF CLOSURE DATU OP REMOVAL Olt <br /> A (GALLONS) CURRBIS LY OR PREVIOUSLY IF CURRFXrLY EMPTY IF PERMANFNTLY CLOSED CLOSU1U5 IN Ill-ACIi <br /> N <br /> K <br /> I <br /> N <br /> F <br /> 0 <br /> TIDS FORM IIAS B OMPLETED UNDER PENALTY OF PERJURY,AND TO Till:BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> III <br /> AS <br /> TITLE i ,� DATE <br /> OFFICE USE ONLY <br /> SWEEPSM Ef:tl LOCCODEms-r CODEMACIMUG'T sEXEbIPT UGI' MCLOSEDUG'1' SWCGPSPRGM/SUBCODL UA'fli <br />