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Underground Storage Tank Program - farm Tank Info•ation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME CON'T'ACT NAME <br /> F <br /> C ADDRESS(Street addrea of TANK location) PHONE p (with area code) <br /> L <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T % .�, i. - �'[7 <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 OPERAI'01(CONTACI'NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATORPHONEN (wilhareacode) <br /> P. <br /> A <br /> T CITY STATE I "LIP CODF. <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 OWN ERCONTACI'NAME <br /> O <br /> NR <br /> MAILING or STREETADDRESS OWNER PONE k(with area code) <br /> E <br /> R CITY STATE I ZIT'CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> ,I. 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 STORED ESTIMATED DATE?LAST USED, METHOD OF CLCGURE DATE 01'REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENILY EMPTY IF PliRMANENILY CLOSED CLOSURE IN PIACI: <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> TIUS FORM IIA$BEEN COMPLETED UNDER PEN IT PERJURY,AND TO TILE BEST OF MY KNOWLEDGE,IS TRUE AND CORRI.CT. <br /> i <br /> AMETITLE Ti/(f DALE <br /> OFFICE USE ONLY <br /> SWEEPS ODMPN L CCODE DLS"1'CODENACITVLUG'I' I NEXEMPTUG'f NCIOSEDUG'I' SWEUIS'PIIGM/SUDCODE DA'I'li <br />