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rFAUnderground Storaerank Program - Farm Tank Iormation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FAIRM or BUSINESS NAME CONTACf[NAME <br /> W0'U <br /> C ADDRESS(Street address of TANK location) PHONE# with area code) <br /> ILAI / 0 33 /Rk 4191/ Ag r I7� <br /> T CITYl'c— 753 ZIP CODE NEAR,G� SS V <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification �H-C r <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from abode j%c ; I ^-`ILiH <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS J 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 /> O <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 /> CHECK APPROPRIATE BOX <br /> ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT 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 CHEMICALS 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 <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLF rED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAM TITLE DATE S <br /> OFFICE USE ONLY <br /> / SWEEPS# COMPk I LOC CODE DIST CODE#ACnVF UGT I it EXEMPT UGT 1#CLOSED UGT I SWEEPS PRGM/SUB CODE DATE <br /> ^(�) EH 23 044(12/88) <br />