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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 _ CONTACT NAME <br /> A <br /> C ADDRESS(Street address of TANK locati4 PHONE N (with area code) <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> Y C CK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> NAME OPERATOR CONTACT'NAME <br /> 0 z <br /> P , ( t- � e, -_ , t L % ., (' <br /> E MAILING or STREET ADDRESS OPERATOR PHONE N (with area code) <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 .% OWNERCONTACTNAME <br /> /i <br /> 0 C l I� -Z2L , x` <br /> W MAILING or STRII TADDRESS OWNER PHONE N(with area code) <br /> E ✓ (�`�t �— c l i'�cr <br /> R CITY STATE ZIP CODE PAYMENT <br /> RECEIVED <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,I, ACTIVE FARM TANK SITE (One or more underground TANKS [,P— yluy (ti city) <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(List additional tank Information on separate sheet If needed.) <br /> T DANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY/ IF CURRENTLY EMPTY IF PERMANEN'T'LY CLOSED CLOSURE IN PLACE <br /> N <br /> K G'z c: .2�. i <br /> N <br /> nU i FORM 11AS-BEEN MPLKM UNDER PENALTY OF PERJURY,AND TO"IE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME �' — TITLE .�` [_ DATE ,, 7 <br /> OFFICE USE ONLY <br /> SWEEPSs COMPa LOC CODE DIST CODE N ACl1VEtrG'f NEKEMPI'11G'1' aCLOSEDUG'I' SWU-PSPRGM/SUUCODE DA-1 1: <br /> EH 23 044 12188 <br />