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f Underground Stord!�Tank Program - Farm Tank 011ormation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSIFFFSS NAME CONTACT'NAME <br /> A A SNE 7, {- <br /> C ADDRESS(Street address Of TANK location) PHONE# (witharcacode) <br /> 1 CITY STATE I ZIP CODE NEAREST CROSS STREET <br /> T <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 01'6RAT'OR CONTACT'NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERAI'OR PI ZONE N (with arca code) <br /> R <br /> A <br /> T CITY STATL I ZIP CODE <br /> 0 <br /> RI CHECK HERE is this ADDR13SS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWN ER CONTACT NAME <br /> 0 <br /> NMAILING 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 /> T ACnVE 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 TAW USED MGI HOD OF CLOSURE DATEOF REMOVAL OR <br /> A (GALLONS) CURRPlnl.Y OR PREVIOUSLY IF CURRENILY EMPTY IF PERMANENTLY CLOSED CLOSURE IN NACG <br /> N <br /> K Soo o �� / 98 � <br /> 1 <br /> F <br /> 01 1 <br /> T1US FORM HAS DEIN COMP L UND TYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE ISTRUE AND CORRECT'. <br /> "TITLE � L., UATLI��, <br /> OFFICE USE ONLY <br /> SWEEPSN 1 WMPM I LOC CODE DIST CADS Y ACIIVE LXYI' NEXEMPT'UGI' 0CfASIi1)UG'ISWJILJ-51%GMISU13 CODE DA'I'li <br /> Eli 23 044(12/88) <br />