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Underground Sttcege Tank Program - Farm Tanbnformation Form ' FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A o - o C ADDR (Street address of TANK location) PHONE# (with area code) LI 6eq VC7 o I CITY STATE I ZIP CODE I NEAREST CROSS SEET T � 0G- ' oN A S.ZOS Gi / Y CHECK HERE if this ADDRESS should he used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) O NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area tale) R A T CITY STATE I ZIP CODE O R CHF,CK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) NAME OWNER CONTACT NAME O NMAILING or STREET ADDRESS OWNER PHONE#(with area code) E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX "'/5) .1. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) P E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N pp / K 2coo S74 Fes( O�� I N F 0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME I I TITLE E r DATE OFFICE USE ONLY SWEEPS COMP# LOCCODE DISTCODE#ACTIVEUGT I#EXEMPTUGT #CLOSEDUGT I SWEEPS PRGM/SUBCODE DATIS EH 23 044(12/88)