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Underground Store Tank Program - Farm TanAormation 4441AVYV <br /> J <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FAR or BUSINESS NAME CONTACT NAME <br /> AC' HEAD 4 <br /> ' e r �%'/1 F <br /> C ADDRESS(Street address of'TANK location) PHONE# (with area c09TQ SIT/SERVICES <br /> I /'5aC S'. Sc�X�Ch // 9) 9- <br /> I CI � <br /> IS <br /> Eoi alC r7 CC3 �rj 3aC N F.C FCIetOS /TeHrf PC OC/ <br /> T <br /> Y I 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 I 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 /> 0 <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHFCK 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 g capacity) <br /> P ALL underground TANKS at site = to or < 1,100 gallon ca acit <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 METI IOD 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 SOC sc- C! <br /> I <br /> N <br /> F <br /> O <br /> THIS FO EN COMP UN PEN LTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAM <br /> N n,i_� G <br /> r. c TITLE DATE. / of / <br /> OFFICE USE ONLY <br /> SWEEPS# CAMP# L.00CODIi D1sTCODH#ACIVEUG'I' #EXEMP'I'UG•1' #CLOSED UGC' SWEEPS PR(iM/SUB CODE DATE <br /> EH 23 044(12/88) <br />