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Underground Storage Tank Program - Farm Tank Information Form <br /> /FA,CILITY/BITE INFORMATION (Complete this form for each FARM TANK location.) <br /> / I' rARM or 13USINESS NAME CONTACI`NAME <br /> A H4 k S A x+24' o r2r <br /> C ADDRESS(Street address of"TANK location) Pl IONE IJ (wish arca code) <br /> I l� 2 S. VAti ALLEN F' <br /> L <br /> I CITY STAfE I 'LIP CODE NEAREST CROSS sTREET <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACI'NAME <br /> P 4 66ert t-�OaQ2 S cam' E-Ie— OL' c"-� <br /> E MAILING or STREET ADDRESS OPERA OR PHONE H (with area code) <br /> R e�j 2 OS <br /> A <br /> T CITY STATE ZIP CODE <br /> 0 S"�CC�G I O k ) 'C FS- 1�5 <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 /> 0 sD H02P-4 <br /> NMAILING or STREET ADDRESS OWNER PHONE##(with area code) <br /> Ea 1ETZ S �3 Z+'i !LJ <br /> R CITY STATE Z1P CODE <br /> �tiVt LLQ C.�4 g4szf (41S) <br /> CHECK HERE if this A.13DR'r'SS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T 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 [our < 1,100 gallon capacity) <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 TANKSIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD Of CLOSURE DATF OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURIZEI 'I'LY EMPTY IF PERMANl NTLY CLOSED CLOSURI;IN PLACE <br /> N <br /> K #� + <br /> N <br /> F <br /> 0 <br /> TINS FORM HAS BE a OMPLI TED UNDER PENALTY OF PERJURY,AND TO THE RESTOF MY ha4OWL,EDGE,IS TRUE-AND CORRECT. <br /> NAME TITLE. r� ` DATE C" <br /> OFFICE USE ONLY <br /> SWEETS H COMP H LOC CODE DIST CODA', H A011VI3 UGT H EX IMPT UGT H CLOSED UGI° SWEEPS PRGM1SUB CODE DATE <br />