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` Underground Storage Tank Program - Farm Tank Normation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FA-RMM or BUSINESS NAME;� CONTACT NAME <br /> A lei "i`ra `�l'OS . ftlmLe <br /> C ADDRESS(Street add of TANK location PHONE# (with area code) <br /> L 6-1 at E err 1 1 0q -FA -CvCoS <br /> I CITY �}, S / <br /> STATE <br /> ZIP COODDENEAREST CROSS STREEET�( <br /> T may 1�CC� C14 `63a, U✓11 N-\ i <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERA'T'OR 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 STATE I 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 OWNER CONTACT NAME <br /> O <br /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,I• ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g g capacity) <br /> P ALL under round'TANKS at site to or < 1,100 gallon ca acit <br /> E PERMANENTLY CLOSED FARM"TANK SITE (ALL underground TANKS at site removcd r 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 ATE OF REMOV OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED LACE <br /> K I()04 CG( 497 llPJma rea 8-7 <br /> I <br /> N <br /> F <br /> O <br /> 1 1 <br /> THIS FORM HAS BEEN COMPLE-IED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE DATE l :3 <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOCCODF. DISI'CODE#ACTIVEUGT #mrNPTUGT 1#CLOSED UGT I SWEEPS PRGMi3UB CODE DA"1'E <br /> EH 23 044(12/88) <br />