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V Underground Sto&e Tank Program - harm Tan 9iformation Form <br /> FACILITY/SITE INFORMATIO 'omplete this form for each FARM TANK tion.) <br /> r <br /> F <br /> FARM or BUSINFSS NAME CONTACT NAME <br /> A Js et I .t_ 'WC � �—Z) �r �l� <br /> C ADDRESS(Street address of TANK location) PHONE# (with are c e) <br /> L ,5rm \ / d U !�' Q <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T d(' 0 7 <br /> Y a �� id- dl <br /> CHECK HERE if this ADDR(ES-S should be used for Legal Notification <br /> OPERATOR INFORMATIOADDRN ESS (Complete if information from above.) <br /> D0- <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (wilh area code) <br /> R �— <br /> A <br /> T CITY STATE ZIP CODE <br /> 0 �-- <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 ! o�✓� �o sti <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E j 0 Q Oj� 339-?,f;P <br /> R CITY STATE ZIP CODE <br /> U 4" ICA, sz3 <br /> CHECK HERE if this ADDRESS 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 = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CI_ s FAp.M 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 MF,TI-IOD 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 COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> [NAME - TITLE DATE <br /> OFFICE USI: LY <br /> SWEEPS# COMP# I IAC CODE DIST CODE#ACTIVE UGT I#EXEMPT UGT #CLOSED UGT I SWEEPS PRGM/SUB CODE DATI <br /> LA <br /> EI 123 044(12/88) <br />