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Underground Storw- Tank Program - Farm Tank formation Form t FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A C ADDRESS(Stre address of TANK location) PHONE.# .(with area code) I L — I CITY //STATE ZIP COD___jE NEAREST CROSSASTREET T l.�lt S 2— Y CHUCK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) 0 NAME. OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A .I. CITY STATE 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 OWNER CONTACT NAME O wlcq W MAILING or STR ET ADDRESS OWNER PHONE#(with area code) N E — n:q R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y ALL under round TANKS at site = to or < 1,100 gallon capacity) P EXEMPT FARM TANK SITE ( g g P y) 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 if needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K 500 &Ad' 1 n t° /n" ttS�• I N F 101 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND To THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME TITLE DATE j— OFFICE USE ONL !� SWEEPS# I COMP# I LOC CODE DIST CODE#ACTIVE UGT #EXEMPTUGT #CLOSEDUGT SWEEPSPRGM/SUBCODE DATE EH 23 044(12/88)