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RECEIVED <br /> `j1'--Underground Sage Tank Program - farm Tank Information lj ,Ar 1 1 1900 <br /> FACILITY/SITI;INFORMATION (Complete this form for each FARM TANK location.) -ENVIRONMENTAL HEALTH <br /> F FARM or BUSINESS NAK CONTACT NAME <br /> A /. LP/J22 <br /> C ADDRESS(Street address of TANK location) j PHONE q (with area code) <br /> I a / q �y <br /> L Z 7. L� t 7± ! ""� 3✓ <br /> 1 CITY l_ S ATE ZIP CODE NEAREST CROSS ST'REGr <br /> T <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> v <br /> OPERATOR INFORMATION &ADDRESS (Complete If Information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS <br /> R OPERATOR PHONE N (with area cafe) <br /> A <br /> T CITY SPATE LIP 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 OWNERCONTACTNAME <br /> W— <br /> N <br /> OWNER PHONE p(wish area tale) <br /> 7 STATE ZIP CODE <br /> RESS 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 <br /> (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 CHP.MICALS STORED ESTIMATED DATE LAS r USED METI{OD OF CLOSURE DATE OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLASUkE IN PLACE <br /> N <br /> K 75"D CGS 04111 ec- �/ /9P°I <br /> I L y,� l n I oC 6 / Wy <br /> N <br /> F <br /> O <br /> T'IUS FORM ILILS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME <br /> CLi K.ti TITLE <br /> OFFICE USE ONLY DATE I <br /> n)II <br /> PH LOC CODE' DISTCODE M ACITVE UG'f 0 MFMT'UG'1' #CLOSED UGT SWEIIPS PaGM/SUO CODEUAT'lif1H ndd noiaux <br />