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Underground Stora#Tank Program - farm Tank Formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME <br /> i <br /> G �� �� CONTACTNAME <br /> A A �,i rel L o o l's CAV-k L6 <br /> C ADDRESS(Street address of TANK Iocati n).4JN/0 r//S�/ <br /> L I\ I � , 7 L PHONE N (with arca code) <br /> �" "7 � � �,� I �,�1 , til <br /> I CITY STATEZIP CODE NEAREST CROSS <br /> T <br /> I I- CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> P 1JAhlf OPERATOR CONTACT NAME <br /> E MAILING or STI,�EETT ADD TRESS j <br /> R (J OPERATOR PHONE N (with arca tole) <br /> A QX q <br /> LRCITY SPATE ZIP CODE <br /> S �Lv'V �� � �1 <br /> CHECK HERE!s Ihia ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete If different from above.) <br /> NAME <br /> O OWNERCONTACTNAME <br /> S / P <br /> NMAILING or SIRE T ADDRESS OWNER PHONE N(with arca code) <br /> E <br /> R CITY STATE 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 <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site u to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SITE <br /> (ALL underground TANKS at site removed or closed in nlace) <br /> UNDERGROUND TANK INFORMATION (List additional tank Information on separate sheet If needed.) <br /> T TAW SIZE CHEMICAL MRED <br /> A (OALIANS) CURREN LY OR PREVIOUSLY ESTIMATED <br /> �UIUy DATE LAST <br /> Y�ED Ur WITIO POO CL CLOSED SUR DATE O RI:REMOVAL <br /> It <br /> N <br /> K l c -- <br /> c� � <br /> I cci nt <br /> N <br /> F <br /> 0 i <br /> TIUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PEW URY,AND TO TILE BEST OF MY KNOW]l IS TRUE AND CORRECT. <br /> NAME--' '� <br /> zr L TITLE rhe <br /> OFF[C USE ONLY DAM <br /> F <br /> I <br /> WFXPSN COMPN I.00CODEDISTCODENACTIVEL'GT Nk'XEMp1'UC'1' MCIOSFDUCT SWEII'SPRGA1iS000ODE DATE <br /> EH 21 044(1 MR) <br />