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Underground Stolfe Tank Program - Farm Tan.01formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CO TACT NAME <br /> A Y �1/ l t l 7-*-/ ( J/ �i4 �l✓ <br /> C ADDRESS(Street address of TANK location) PHONE# (with arca code) <br /> L 90 / .s" Z Zn9 - 2 39:-z�17 <br /> 1 CITY <br /> / STATE �}ZIIP—CODE NEAREST CROSS STREET <br /> T /�-4 �EC/� (,:A 7 S5'3 6 #L /-:-- <br /> Y v CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if Information different from above.) <br /> O 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 IIERE 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 /> 0 <br /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> .1. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P LZ 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 (I.Ist additional tank Information on separate sheet if needed.) <br /> T TANK SIZE. CHEMICALS SPORED ESTIMATED DATE LAST USED METHOD OF CIASURP_ DATE OF REMOVAL._OIL <br /> A (GALLONS) CURRENTLYORPREVIOUSLY IPCURRENTLYEMPTY IF FERIVIANW11-Y CLOSED CLOSURE IN PLACE <br /> N <br /> K — �✓ <br /> I LTJml J61S <br /> N <br /> F <br /> 0 <br /> 1 77 <br /> THIS F RM IIAS BEEN COMPLYTED UNDER PENALTY OF PERJURY,AND TO TIIE BEST OF MY KNOWLEDGE,IS TRUE AND CORRE(,T. ; <br /> NAM TITLE x(jl% DATE �', / <br /> OFFICE USE ONLY <br /> SWEEPSM COMP U)CCODLDIS'I'CODENACIIVLLrT NEXEMPT Ual' NCLU.SEDUGI' SWEEPSPRGMrSUBCOUE UA'1'li <br /> EH 23 044(12,/83) <br />