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Underground Sto _,,Tank Program - Farm Tan' ,,-.,Jrmation Form FAr—ILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F, FARM or BUSINESS NAME CONTACT NAME A C ADDRESS(Street address of TANK location) PHONE# (with area code) 1 ,Q — L L 1 CITY STT9 ZIP CODE NEAREST CROSS smkgr T �GSG4u> % fZ 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 O NMAILING or STREET ADDRESS OWNER PHONE#(with area code) E kimmaq �Oq—tqyp .�z R CITY I srArE I ZIP CODE L CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX ,l, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) 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 OP REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K I N F O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAMEt- TITLE W DATE OFFICE USE ONLY SWEPPSNCOMP# IOC CODE DIST CODE#ACTIVE UGT I#EXEMPTUGT #CLOSEDUGT I SWEEPS PRGMISUB CODE DATE EH 23 044(12/88)