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Underground Stowe Tank Program - Farm Tan fnformat� Form <br /> FACILITY/SCFE INFORMATION (Complete this form for each FARM TANK location.) l/Jh <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> C ADDRESS(Street address o " ANK location) PHONE# (with arca c e) <br /> >fed e <br /> L <br /> I Cl E "LIP CODE I NEARES7 CROSS STREET <br /> T •k �` � 3�� LrQ. 7 <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAME 1 / OPERATOR CT NAME <br /> P V 2 1 �1 U 1 1LRgl <br /> E MAILING or STREET ADDRESS V OPER OR PHONE# (wt code) <br /> R <br /> T let <br /> CITY STATE ZIP CODE <br /> 0 Esta(0"153Zp t FVVi <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. -rufM)TIS <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if(his 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 EMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <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 CIIEMICAIS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> I rf V2 <br /> N <br /> F <br /> 0 <br /> THIS FORM H ' N COMP L D NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND ORRECT. <br /> NAME F1 <br /> TITLE / DA <br /> OFFICE USE ONLY er <br /> SWEEPSM I COMPAI LOC CODG DIST CODE#ACTTVEUGT NEXFMPTUGT 10 CLOSED UGT SWEEPS PRGM/SUBCODB DATE <br /> LI 123 044(12/88) <br />