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Underground Storagfank Program - Farm Tank Ion ormation Form <br /> FACILITY/SITZ;INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CON'I'ACI'NAME <br /> A 1, 1, di /—&\✓ yYl iA / C,/),11';1 /�61ii�r1 . <br /> C ADDRESS(Street alkimm of TANK location) PHONE k (with arca code) <br /> L / ,S 5,-, F,2 /S/ 7 <br /> I CITY // ATE ZIP CODE NEAREST CROSS STREET <br /> T / r rl {' �' '% l �) / 1' : 1. q b- / /1 A,di ?c1- <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFOPry TION &ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT'NAME <br /> P <br /> E MAILING or STREET ADDRESS ! OPERATOR PIIONE 11 (Kith area code) <br /> R � ✓/� <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 7 OWNER CONTACT NAME <br /> NMAILING or STREET ADDRESS ' r- OWNER PHONE N(with area code) <br /> E �G � ` 67 <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,1, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE 10 6� CA/, (ALL underground"TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS al site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional tank Information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALSSTORED ESrIMA11-i'D DATE USED MCItiODOF'CIASURE DA'Z'E 01;REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENILY EMPTY IF PERMANENTLY CIJ-XSED CLOSURF IN I'IACE <br /> N <br /> K �) <br /> I o <br /> N <br /> F <br /> 0 <br /> TIES FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TILE BEST OF MY KNOWLEDGE,IS TRUE AND CORHI?CI'. <br /> NAME 77-77, TITLE P" tom/ i DATE 3 - <br /> OFFICE USE ONLY <br /> SWLhPSM I DOWN IOCCODEDIS'I'CODEaACIIVEUG'I' I 0EXEMPI'UG'I' 0Ct.U.SED UGI SWEEP51'RGMi5UU CODIi DA'lli <br /> Eli 23 044(12188) <br />