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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME / CONTACT NAME <br /> A I chi !, A H <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I CITY STATE ZIP CODE NEAREST CROSS s nw-'ET <br /> T �5C14 N ( X14-32 0 5/---X? , -n <br /> Y vjCHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> O NAME OPERATOR CONTACI'NAME: <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PI ZONE N (with area code) <br /> R <br /> TCITY 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 CONTACT'NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE It(with area code) <br /> E <br /> R CITY SPATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g <br /> P ALL under round'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 MGTI IOD OF CLOSURE DA'L'E OI"ItEMOVAI.Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURREN'11.Y EMPTY <br /> IIF PERMANENTLY CLOSED CL.OSURI:IN PIACI: <br /> K CZ•vi d <br /> I <br /> N <br /> F <br /> O <br /> TILLS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND 7'0 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE c1/��rn�•it DATTs ��— �/— <br /> OFFICE USE ONLY <br /> SWL"S M WMP M LAC:CODE D1SI'CODE M AC11VL UGT M IjXEMP1'UG'1' M CI.USED UGI' SWLIjPS PI1GM/SUIi CUDE DA'T'E <br /> R14 23 644(12, <br />