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Underground Storgp Tank Program - Farm Tan*formation Form <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> 1, FARM or BUSINESS NAME ` CONTACTNAME <br /> A XQ C A. <br /> C ADDRESS(Street address of TANK location) PHONE M (with ama code) <br /> L <br /> I CI7 STATE ZIP CODE I NEAREST CROSS STREET <br /> T <br /> Y CIIECK IIERE if this ADDRESS should be sed for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if Information different from above.) <br /> 0 NIOPERATOR CONTACT NAME <br /> P CtS2f <br /> E MAILING or STREET ADDRESS . OPERATOR PHONE N (with area code) <br /> R 'SZ 53 E. IN <br /> A <br /> T CITY STATE ZIP CODE <br /> 0k-bj <br /> RI CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> 1'ROI'EIYTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAMEii OWNER CONTACT NAME <br /> 0 C i,orf I fC e <br /> NMAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> E I vS — r— Co lolbef-oloy 5 <br /> R CITY I &TATEZIP CODE <br /> dJv <br /> lc74 6522��—[ <br /> CHECK HERE if this ADDRESS should be used for(.egal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT(FARM TANK SITE (ALI,undcrground TANKS at site = tour < 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 TANKSIZF CIIEMICAISSTORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K SOD 6CLC, <br /> I <br /> N <br /> F <br /> O <br /> '1'DIS FORM IIAS BEEN COMPIA-:PED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNLLOWWLEDGK IS TRITE AND CORRECT. <br /> NAME TiTLE�S{G� CgarSPrVK�L�" DATE <br /> OFFICE 9SE ONLY <br /> SWIiEPSN CAMPN LOC CODE DIST CODENACTIVEIIGT #13XLMPTUGT NCIOSEDUGT I SWEEPS PRGM/SUBCODE DATE <br /> 1:1123 044(12/88) <br />