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Undergroundoorage Tank Program Farm *k lnfurmation�fn' r Li <br /> FACILITY/SITE, INFORMATION(Complete this form for each FARM TANK location.) T5 fpp�'l <br /> FARM or BUSINMS NAME UNVIROPIJMEN-�A!-HFA I t <br /> CON,rAcr NAML-'-"- <br /> A T IV Pil /,,w i-�- <br /> C ADDRESS(Street address of'TANK location) <br /> I ! PHONE N (with area code) <br /> L <br /> C CITY <br /> A g1l M <br /> Olt�S 5 <br /> ITY <br /> < <br /> STATE- ZIP CODE NEAItEs,rcitossST1(EE`T <br /> T t< tn <br /> t <br /> y C 11 <br /> CI ILICK HERO if this ADDRNSS should be used for Legal Not ificudon <br /> OPERATOR INFORMATION &ADDRESS (Complete If information different from above.) <br /> 0 NAME OPE"I'Olt CONTACI'NAME- <br /> P --s 4f <br /> I- I MAILING Or STRL-E-7r ADDRESS <br /> R OPERATOR PHONE- # (with area code) <br /> A <br /> T CITY 761 CODE <br /> 0 <br /> R <br /> C1113CK 1.181113 is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME <br /> 0 cl OWNER CONTACT NAME <br /> W MAJUNG or STREET ADDRESS <br /> N OWNER 1`1101413#(with area code) <br /> E <br /> R CITY <br /> 7A <br /> I'COD <br /> STATE rf 13- <br /> CHECK HERE if this ADDHHSS should be u.,ted for Legal Nolificaiion <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or marc underground'TANKS > 1.100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL undcrground'FANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SI'rE (ALL underground TANKS at site removed or closed in place) <br /> UNURCROUND TANK INFORMA'I'lON(List additional tank Information on separate sheet If needed.) <br /> T rANKSI7jj CHEMICALS STORED EFrIMA7T,'DDA'I`ELAST USLD1 - ME-1711013 OF Cj_()SURp, <br /> A (GALLONS) CURKWI-Ly OR PREVIOUSLY It:CURREN'll-Y Empl,y DATE OF Ri"MOVAL Olt <br /> N � IF PER)AANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> F <br /> 0 <br /> Tilts FOjjM IIAS BEEN COMPLIrrED UNDER PENAIXY OF PERJURY,AND TO III)..]I"- T OF MY KNOWLEDGE,IS TRUI'ANJ)coRlUECT. <br /> NAME &7— ()t7/) - <br /> '11TI-13, <br /> OFFICE USE ONLY <br /> LOC CODE+ I)JS'rWDE #ACI'IVii U(;'j' #aj-*MPTUGI' NCE-()Sf:l)UU'I. I "iwfT.fSPJ(GM6'UBCODiI DATE <br /> 1:1123 044(121813) <br />