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Underground Storage Tank Program - Farm Tank Information Form FACH1TY/SITE INFORMATION(Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A C ADDRESS(Sheet address of TANK location) PHONE N (with area code) L fo q- 3 6VS I CITY STATE I ZIP CODE I NEAREST CROSS STREET T , t Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) 0 NAME OPERAI'ORCONTACI'NAME P E MAILING or STREET ADDRESS OPERATOR PHONE N (with area code) R A T. CITY STATE I 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 OWNERCONTACTNAME O NMAILING or STRE�TADDRESS OWNER PHONE N(with area code) E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX .L. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y P EXEMPT FARM TANK SITE (All,underground TANKS at site = to or < 1,100 gallon capacity) 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 U needed.) T TANKSIZE CHEWCAfS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL Olt A (OALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K I f N F 101 1 TIUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME TITLE DATE _- OFFICE USE ONLY SW[:EPSY COMPY IDC CODE DIS'1'CADEYACI1VE UOT sEXEMP1.UG'1' 140 CLOSED UG'1' I SWEEPS PRGM/SUU COUE UA'1'li IN 23 044(1?JM)