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Underground Sto&e Tank Program - Farm TanO►formation Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM o USINESS NAME CONTACT NAME C ADDRESS(Strut address of TANK location) PHONE# (with area code) 1 _ 7oZD 20 Sal 3 y?a L I CITY r STATE ZIP CODE NEAREST CROSS STREET T f 1533 6 'y ECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) NAME OPERATOR CONTACT NAME P 11 a m 0 a6 E MAILING or S� :SS OPERATOR PHONE# (with area code) R A .l. CITY I STA71 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 O W MAILING or STREET ADDRESS OWNER PHONE#(with area code) N E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) P E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) T TANK SIZE MI AIS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURF, DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE Ka0B D S /yOB ��t I N F 0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME TITLE DATE -,S=f OFFIC SE ONLY SWEEPS# COMP# LOC CODE DIST CODE#ACTIVE UGT #EXEMPTUGC #CLOSEDUGT I SWEEPSPRGM/SUBCOLE— EH 23 044(12/88)