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Underground Stooge Tank Program - Farm TanOnformation Form <br /> t FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A Cc <br /> � J N7� SES Ncb"tiT OUAkac. <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I O - !I/ o� J1 d 5 -9I i <br /> L <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T 1 1 t 01 Cf� G�I U c l 7 <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE ZIP CODE <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACTNAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T 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 /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLa9URE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM I{AS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TIIE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE / N/ _ DATE a <br /> OFFICE USE ONLY <br /> SWEEPS# (AMP# LOC CODE I DIST CODE#ACFIvE UGT #EXEMPT UGF #CLOSED UGf SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />