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Underground Stooge Tank Program - Farm Tan jtform , FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) MEIVED FARM or BUSINESS NAME- CONTACTNAME 4 MUD UD ALT A / Aalc/- C ADDRESS(Street address of TANK location) PHONE M (witha e are T L 03 S�c .v lcc ,9 3 / S' T CITY STATE ZIP CODE NEAREST CROSS STREET T �SC IG n/ 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 N (with area code) R A T CITY STATE I 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 0 N MAILING or STREET ADDRESS OWNER PHONE'N(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• ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) 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 DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K g E' 6 N F O TIIIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE V J URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME TITLE - DATE/o /Z—f OFFICE USE ONLY SWEEPS COMPN LOC LADE DIST CODEJ N ACTIVE IKiT NEXEMPT UG'f NCL.OSED DOT SWEEPS PRGM/SUB CODE DATE El 123 044(12/88)