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Underground SteVe Tank Program - Farm Tanjinformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A A `�(' <br /> PHONE li (with area code) <br /> C ADDR S(Street address of TANK location) <br /> L SPATE ZIP CODE NEAREST CROSS STREET <br /> 1 CI`T'Y <br /> Y CHECK IJERE 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 /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> ASTATE ZIP CODE <br /> T CITY <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 /> OWNER CON'T'ACT NAME <br /> NAME <br /> O <br /> W MAILING or "TREET ADDRESS OWNER PHONE k(with area code) <br /> I; <br /> R CITYSTATE ZIP CODE <br /> C� S 31 <br /> CHECK HER11 if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> T <br /> Y EXEMPT FARM'fANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <br /> E PERMANENTLY CLOSED FARM TANK SI'rE (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 <br /> DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENCLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLEXED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRF.C'C. <br /> TITLE <br /> NAME <br /> DATE 6 ,v <br /> OFFICE USE LY <br /> SWEEPS q COMP N LOC CODE DIST CODE H ACTIVE UGT q EXEMPT UGT b CIASED UGT SWEEPS PRGM/SIIB CODE DATE <br /> El 123 044(12/88) <br />