BILLING - Laserfiche WebLink

Home Browse Search

Underground Storage Tank Program - Farm Tank Information Form FACILITY/SITE INFORMATION (Complete this Corm for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A MM IOD OF CUCSURE IF PERMANENTLY CLOSED DATE OF REMOVAL Olt CLOSURE IN PNCE C ADDRESS (Strom address of TANK location) PHONE # (with area code) I or STREF1'ADDRESS OWNER PHONE Y (with area code) L I CITY STATE ZIP CODs NEAREST CROSS S'fREEf T CHECK HERE if this ADDRESS should be used for Legal Notification I I Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION & ADI)RESS (Complete if information different from above.) 0 NAME OPERATOR CONTACI' NAME P MM IOD OF CUCSURE IF PERMANENTLY CLOSED DATE OF REMOVAL Olt CLOSURE IN PNCE E MAILING or STREET ADDRESS OPERATOR PHONE # (with area code) R or STREF1'ADDRESS OWNER PHONE Y (with area code) A T CITY STATE ZIP CODE 0 CHECK HERE if this ADDRESS should be used for Legal Notification I F O R CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION & ADDRESS (Complete if different from above.) CHECK APPROPRIATE BOX .I. NAME, OWNER CONTACT NAME 0 MM IOD OF CUCSURE IF PERMANENTLY CLOSED DATE OF REMOVAL Olt CLOSURE IN PNCE P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) NMAILING or STREF1'ADDRESS OWNER PHONE Y (with area code) E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX .I. TANK SIZE (GALLONS) ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y MM IOD OF CUCSURE IF PERMANENTLY CLOSED DATE OF REMOVAL Olt CLOSURE IN PNCE 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 separute sheet If needed.) T A N TANK SIZE (GALLONS) CHEMICALS STORED CURRENTLY OR PREVIOUSLY ESTIMATED DATE LAST USED IF CUJU1EN LY EMPTY MM IOD OF CUCSURE IF PERMANENTLY CLOSED DATE OF REMOVAL Olt CLOSURE IN PNCE K I N F O TTUS FORM 11AS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO "IE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. NAME 'ITrLE DATE OFFICE USE ONLY SWEEPS COMP# LOCCODE DIST CODE#ACIIVEUGT anxEMPI'UGI' #CLOSED UG'1SWEEPS PRGM/SUU CODE DATE. W 45 U44 (1 LJtlts)