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Underground StoraAWank Program - Farm Tank Iwination Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME / CONTACT NAME A S (7 C ADDRESS(Street address of TANK location) PHONE# (with area code) L I CITY STATE ZIPCODE NEAREST CRO S STREET T s i Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) 0 NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A .I. CITY S'CATE ZIP CODE O R CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) NAME - OWNER CONTACT NAME O N MAILING or STREET ADDRESS OWNER PHONE#(with area code) E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX T ACCIVE FARM TANK SITE (One or more underground TANKS > 1,1.00 gallon capacity) Y (ALL underground at site = to or < 1,100 gallon capacity) P EXEMPT FARM TANK SITE E PERMANENTLY CLOSED FARM TANK SITE (ALL,underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DA'IT:LAST USED METI IOD OF CLOSURE DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURIiEtJFLY EMPTY IF PE;RMANEN'ILY CLOSED CLDSURE IN PLACE N K E56L — E — Z I N U S F o Ss0 THIS FORM IIAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AN CORRECT. NAME TITLE DATE, OFFICE USE ONLY SWEEPS# COMP# LCX;CODE DIST CODE#ACTIVE UG-17 #EXEMPTUGT It CLOSED UGT SWEEPS PRGM/SUD CODE DATE EH 23 044(12/88)