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Underground Ste Re ,rank Program - Farm Tan' formation Forin <br /> hACILII'Y/Sl'1'E INFORIVIA'I lON (COP this form for each FARM TANK location.) <br /> F"NAM or 13USINESS NAME' C <br /> C ADDR ,' S(Street address of'FANK location) 11 (with arca c(de) <br /> L <br /> I CITY STATE "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 <br /> NAME OPERATOR CONTACT NAME <br /> F <br /> E MAILING or STREET ADDRESSOPERATOR PHONE N (with area code) <br /> R <br /> ASTATE ZIP CODE <br /> T CITY <br /> O <br /> R CHECK IiERE is this ADDRESS should be used for Legal Notification. <br /> I'RO11ERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CON'T'ACT NAME <br /> G Qi' aj l <br /> W MAILING or TTtEET ADDRESS OWNER PHONE It(with area code) <br /> N air' �eP <br /> E <br /> R CITY STATE ZIP CODE <br /> 54237 <br /> CTIECK IIERL if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> I FA(—n:VV.:EF:AIIM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y (ALI,undergroundTANKS at site = to or < 1,100 gallon capacity) <br /> P MP"f .ARM'1'ANKS111EANENTLY CLOSED I-ARM 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 ESTIMA"fI?D DATE EAST USED METI IOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALL.ONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMP'T'Y <br /> IF PERMANENTLY CLOSED CLOSURE IN PEACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> U <br /> 'E711S FORM HAS BEEN COh1Pt.L 1'ED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAMI: <br /> TITLE DATE N 6�v <br /> OFFICE USE LY <br /> 5WE:EPS N COMP N LOC CODE DIST CODE N ACTIVE UGT 0 EXEMPT UGT #CLOSED UGT SWEEPS PIiGM/SUl3 CODE / DATE <br /> 3 ^ - <br /> L-1123 044(12/88) <br />