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Underground Storq*Tank Program - Farm Tank 0ormation Form <br /> FACILITY/HITT;INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A rh1k& � 1�� lei rnIke <br /> C ADDRESS(Street address ofJAI TANK location pp PHONE# (with area code) <br /> I her- P-d 0 q <br /> L <br /> CITY ) STATE ZIP CODE NEARESTCROSSSTREtr <br /> TLl� C� ( �5 Z 11- Rck <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 CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area tale) <br /> R <br /> A <br /> T CITY STATE ZIP CODE <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME I OWNER CONTACT NAME <br /> 0 e • �' , e °' Pen 1'5 e-- <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> R CITY ST TE ZIP CODE <br /> �oQI (w 1 JSzYz <br /> CHUCK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .1. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> YEXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <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 CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 0 9 <br /> N <br /> F <br /> O <br /> THIS FORM HASBE COMPLETE DE PEN OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> iw <br /> NAME e� 5e- TITLE Q t/J+1. DATE . <br /> OFFICE USE ONLY <br /> n SWEEPS# COMP# LOC CODE DIST CODE#ACTIVE HOT #EXEMPT UGT #CLOSED UHT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />