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I (fly .�-"'' 1gott <br /> t� Underground Stove Tank Program - Farm Tanllformation Form <br /> r ,N <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> CONTACT NAME <br /> F FARM or BUSINESS NAME \(Cr2 <br /> A <br /> PHONE# (with area code) <br /> C ADDRESS(Street address of TANK location) <br /> L <br /> CITY /STATE pZIP CODE NEAREST CROSS STREET <br /> T l l 366 G ,�— <br /> Y4WECK, HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> OPERATOR CONTACT NAME <br /> O NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> .I CITY STATE ZIP 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 OWNER CONTACT NA�MF <br /> 06 <br /> ADDRESS OWNER PHONE#(with area code) <br /> W MAILING or STREET <br /> R CI TATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T <br /> •J ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y G� EXEMPT FARM TANK SIZE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <br /> E ( PERMANENTLY Cl..OSED 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 M(GALLONS) <br /> CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DACE OF REMOVAL OR <br /> A URRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACExT L (v ��- f <br /> I <br /> N <br /> F <br /> O <br /> TRIS FORM HAS BEEN CO PLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME <br /> TITLE <br /> OFFICE USE 010,Y <br /> ff <br /> S# COMP# LOC CODE DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />