Laserfiche WebLink
Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARb1 pr B�JSINESS NAMB„ r_ CONIITACT NAME <br /> A 1 Inc ✓ L <br /> C ADDRESS(St t addtm of TAN+ loculi ) PHONH M (wish area code) <br /> L <br /> I CITY/ � �Q S//TAT,E ZIP CODB NFARES'rCItOSS STREEr <br /> T ILLI ( .702 Q V <br /> Y r—F CHECK HERE if this ADDRESS should be used for Legal Notificalion <br /> OPERATOR INFORMATION &ADDRESS (Complete If Informution different from above.) <br /> O N nn OPl Rl TOR CON'rACI'NAME <br /> p 1 ,rl, �f �� 6rr �/u�SCv �1' 1c 4 <br /> E MAILING or AD RESS OPERATOR PI I NEM (with area code) <br /> A -t 3 06 /0. be- V-1 <br /> T C1TfroY � , STATE LP/CODE <br /> O l O .7� . <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMD <br /> INFORMATION &ADRES'JS (Complete if different from above.) <br /> 0 N `I/[ii;VQ0 J— rIpLc4tat"6/ jr & 9�1 OWNERCON,rACrNAME <br /> N MABJNOtxSTREPTADDRESS OWNER PHONE M(with area codc) <br /> E <br /> R CITY STATE I 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 <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> B PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank Information on sepurule sheet if needed.) <br /> T TANKSMO <br /> CHEMICALS STORED ESIIMATCD DAM IAti-r USW MEII IOD OF CLOSURE DATE OF REMOVAL Olt <br /> A (GALLONS) CURRWMY OR PREVIOUSLY IF CURIIENILY EMPTY IF PGtMANEN'ILY CLUSED CLUSUIUi IN PLACU <br /> N <br /> K U h v 9L°U't0V'Cc1 <br /> I <br /> N <br /> F <br /> O <br /> TI US FORM HAS BEEN COMPLSI'ED UNDER PENALTY OF PEW URY,AND TO TIIE BEST OF MY ENO WLEDGF,IS TRUE AN IJ CORIUX71. <br /> NAME `"7 i 'nTLE DATE <br /> OFFICE USE ONLY <br /> SWISEPS11 IWMPAt LOCCOLM DIST CO DE 0 ACIIVE UOT aULMI-1'W'1' 0CLOSEU W'1' SmAim PRGMISUU CUUU UA'I'li <br />