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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) / <br /> F FARM or BUSINESS NAME } CONI'ACI'NAME <br /> A C -r ��,� ll �� � 1 l—{ <br /> C ADDRESS(Strut addreu of TANK location) PHONE# (with arca <br /> L <br /> I CITY STATE I ZIP CODE I 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 ab r I <br /> O NAME OPERATOR Crp TACE'NAME 45' <br /> 1. <br /> 7; <br /> P 1SQ.j� V41 <br /> E MAILING or STREET ADDRESS OPI3RA1'6R PI IONC# (with area code) <br /> It <br /> A <br /> T 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 NAME <br /> O .�.� :; �J9✓Q. <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> .I, 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 CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (I.Ist additional tank Information on sepurate sheet if needed.) <br /> T TANK SIZE CHEMICAISSTORFD FSTIMAIBD DATE LAST USED METI IOD OF CLOSURE DA'Z'E 01:REMOVAL Olt <br /> A (GALLONS) CURRP.NILY OR PREVIOUSLY IF CURRENILY EMPTY IF PERMANENTLY CLOSED CLOSUIU IN PLACE <br /> N <br /> I <br /> N <br /> F <br /> O <br /> TIES FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOME BEST OF MY KNOW LEDGE,IS TRUE AN D CORRECT. <br /> NAME ( 77�, TITLE j J — DA11? <br /> OFFICE 6SF ONLY <br /> SWEFPS# COMP# LOCCODE DLS-1'CODE #ACI1VIi LUT' #UCEMPTUG'1' NCLGSED U61SWEEI51'ILGM/SUU CODh UA'I li <br /> EH 23 044(12/88) <br />