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IUnderground Sto&e Tank Program - Farm Tanformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A S. H D F-%t-4 01-0 P.. Mo21MOTV <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> L <br /> L ,frZ A t&4L-AV I-XC) (4t 02) 3S-4- L <br /> I CITY STATE ZIP CODE I NEAREST CROSS STREET <br /> T L.Argez lr C-A 1/$330 ""-1<4 IJLOELf <br /> Y CIIECK HERE if this ADDRESS should he used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY SPATE ZIP CODE <br /> O <br /> R CIIECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> o <br /> S . KA09 "o"Fc, E• M�t2trt�� C 1 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E 411 LJ LO • cE tLIFNc. TZ--- yoQ3.rZ4 - ! 6C) <br /> R CITY STATE ZIPCODE <br /> 64WI h- *&Vf-a CA <br /> 9a-1 Q3 <br /> CIIECK 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 (ALI,underground'FANKS at site = to or < 1,100 gallon capacity) <br /> E PFRMANENTLY CLOSED FARM TANK SITE (ALL,under round TANKS at site removed or closed in I11a4 <br /> ) <br /> tc F02 <br /> UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) <br /> T TANKSIZF CHEMICALS STORED ISTIMATED DATE LAST USED MGI'HODOFCLOSURF, DATEOF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM IMS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE IIST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME 'TITLE DATE <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODE DIST CODE #ACTIVE UGT #EXEMPT UC7f #CLOSED UGT I SWEEPS PRGM/SUB CODE DATE <br /> EII 23 044(12/88) <br />