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Underground Ste ge Tank Program - Farm TanOnformation Form • FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A , w HN . C ADDRESS(Street address of TANK location) PHONE# (with area code) L W �4 A/, i5' -& - I CITY STATEZIP CODE NEAREST CROSS STREET T 'I/- iwo�w 6y. 93G Y/f'� 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# (with area code) R A T CITY Sl'AIE 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#(with area code) E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX .I. 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 /\1 PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANK at site remov d!+r cloyed in place) NK UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLASURF, DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE. I N F 0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME.- ] TITLE ®�� DATE , OFFICE USE ONLY SWEEPS# COMP# LOC CODE DIST CODE#ACTIVE UGT #EXEMPT UG'f #CLOSED ETJ SWEEPS PRGM/SUB CODE DATE F:H 23 044(12/88)