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Underground Storage Tank Program - Farm Ta information F�� <br /> FACILITY/SI'Z'E 1NFORMA'1'ION *plete this form For each FARM TANK location.) ®®!� <br /> FPADDRESS <br /> S NAME <br /> y( „ I / CONTACTNAME <br /> A '"I zEv�Gt0 pq <br /> f ddress of TANK location) <br /> L S �S�— + PHONEN (witharcacd' ) 20 1STATE ZIPCODE NEARE'STCROSSSTREEf <br /> T YERE if this ADDRESS should he used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete it inrormation different from above.) <br /> O NAME <br /> P <br /> OPERATOR CONTACT NAME <br /> E MAILING or STREET ADDRESS <br /> R OPERATOR PHONE H (with arca cock) <br /> A <br /> T CI lV STATE ZIP CODE <br /> O <br /> R CHECK 11FRE k Ihis ADDRFSS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete irdifferent from above.) <br /> NAME <br /> O <br /> OWNER CONTACT NAME <br /> NMAILING orS1'RL•ETADDItPSS OWNER PHONE#(with arca code) <br /> E <br /> R Cfl'Y S'fATB 'LIP CODE <br /> CI IECK IIERE if this ADDRFSS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SI7T (One or more underground TANKS > 1,100 gallon capacity) <br /> Y / 3sp <br /> P EXEMP'I'FARM TANK SITE,Z 3 -, LE undcrg(ound TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK STfE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet irneeded.) <br /> T TANKSI%E CHEMICAISSTORF.D F-STIMAT )DA77:HST USED METfIODOFCI_OSURE ATIi OF REMOVAI_OR <br /> A (GALLONS) CURRENTLY OIL PREVIOUSLY IFCIIRRINI'I.Yr;Ml'TDATFOF <br /> Y IF PERMANENTLY CLOSED Ui PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> -01 1 <br /> THIS FORM HAS 11155N N COMPLETED VNPy PENALTY Ol'PEXIIJRY,AND'1'O T IJE BEST OF MY KNOWLEDGE,IS TRUE.AND CORRECT. <br /> NAME TITLE DATE- <br /> OFFICE SISI;ONLY <br /> SWI[P.E\N (Y)MPB LOCCOIA: DISTCOD1 NACI'IVIi(K;I' NIiXIiMP'I'l1C:I' MCLOSIiU UG'1' SWEEPS PRGMiSUB CODE <br /> DATE <br /> 1:11 23 <br /> 044(12/88) <br />