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Underground Stogie Tank Program - Farm Tani,./ormation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A to oZ <br /> C ADDRESS(Street address of TANK location) PHONE,# (with area code) <br /> I <br /> L 32 S. me Hfw <br /> I CrrY STATE I ZIP CODE I NEAREST CROSS STREET <br /> T E"5n_-d0 N <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P sood <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> T CITY SfATE ZIP CODE <br /> 0 rs S3� <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 OWNER CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX ENVIIR��pp EN <br /> TAI HF I Tu <br /> .I. ACHVE FARM TANK SITE (One or more underground TANKS > P.1'BCt �bd Cdtc' ES <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 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 TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST I ISED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IFCIJRRI-.Mrl.YEMP'I'Y IF PERMANENTLY CLOSED CLOSURE;IN PLACE <br /> N <br /> K %p J <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE:BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME " I TITLE CJ(.CIA�(/L� DATE <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# IOC CODE DIST CODE#ACTIVE UGT I#EXEMPT UGT #CLOSEDUGT SWEEPSPRGM/SUBCODE I DATE <br /> EH 23 044(12/88) <br />