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Underground Stt+ge Tank Program - Farm TanWformation Form FACILITYISITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A C AbDRESS(Street address of'.ANle location) PHONE# (with area code) I � G i L ICITY STATE I ZIP COD NEAREST CROSS STREET T n.C�v ��- Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) 0 NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A — -- T CITY STATE I ZIP CODE " O R CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) NAME OWNER CONTACT NAME 0 N MAILING 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 T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y EXEMPT FARM TANK SITE ( g g capacity) P ALL underground TANKS at site = to or < 1,100 anon ca acit E `�( PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site remo ed 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 C OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTL D CIASU CE N CT K 0 3 1989 ENVIRON ENTAL iiEALr I t� N F O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME TITLE DATE —�? OFFICE USE ONLY SWEEPS# I COMP# LOC CODE DIST CODE #ACTIVE UGT I#EXEMPTUGT I#CLOSED UGT I SWEEPS PRGM/SUB CODE DATE EH 23 044(12/88)