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Underground St(oe Tank Program - Farm Tanollformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACTNAME <br /> A <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I <br /> L <br /> I CITY STATE I ZIP CODE I NEAREST CROSS STREET <br /> T <br /> Y �-7 CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE I 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 OWNER CONTACT NAME <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> R CITYtt 17 /STATE ZIP CODE <br /> �d <br /> ! C.ECK HERE if this ADDRESS should used for Legal Notification <br /> CHECK APPROPRIATE BOX 4, <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <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 USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> "r <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 /> NAM c'C �- �C -� ` TITLE C <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODE DISTCODE#ACTIVE UGT I#EXEMPT UGT #CLOSED UGT SWEEPS PRGM/SUB CODE DATE , <br /> EH 23 044(12/88) <br />