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Underground fte Tanic program - <br /> FACILITY/SITl INF g arm Ta <br /> ORMATION(Complete this form for each F • for y � <br /> FARM or BUSINESS N ^]tM TANK location.) MAY 2L !("0 <br /> F ME 1 <br /> coNTncr,tUNNiFIVtALHEA�i i <br /> C ADDIS+ g(StreetaddressofTANKIoc ti n) . MIT/J�RVIvCJ <br /> I / <br /> L 1U f (/�` / C CD PHONB M (with area code) <br /> CITYj STATE 'I.IP CODE NPNtPS'f CROS S17(fBC <br /> Y CH CK HERE if This ADDRESS shoube used for Legal Noiificatio <br /> OPERATOR INFORMATION&ADDRESS (Complete <br /> 0 NAME IC Information different from above.) <br /> P OPEIIA'1'Oli CON'fAC1'NAM[; <br /> E MAILING or STR EET.e <br /> R DDRESS <br /> A OPERATOR PHONE N (with area code) <br /> T CITY <br /> 0 STATE ZIP CODP <br /> R <br /> CHECK HERD,is this ADDRESS should be used for Lcgal Nolification. <br /> PROPERTY OWNER INFORMATION &ADDRFsS (Complete If different from above.) <br /> NAME <br /> NO OWNER CONTACT NAME <br /> MAILING or SnWFr ADDRESS <br /> E OWNER PHONE N(with area code) <br /> R CITY <br /> STATE ZIP CODE <br /> CHP.CK HP,RP if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE]30X <br /> T ACTIVE FARM TANK SITP <br /> Y (One or more underground TANKS > 1,100 gallon capa <br /> P EXEMPT FARM TANK SITE city) <br /> E (ALL underground TANKS at site = to or < 1,1U0 gallon ca);Icily) <br /> PERMANENTLY CLOSED FARM TANK SITE <br /> I I'll (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION(List addlllonal tank Informatlon on sepurnte sheet If needed.) <br /> T TANK SW, <br /> CHEMICALS Olt STORED ESTIMATED DATE <br /> A (OAL�ANS) CURRENTLY Olt <br /> PRE <br /> LAST MCrI--IOD OF CL.QSUItE <br /> N L ` 11 CURRENTLY EMPTY IF Pf3RMANENII CLQ D DATE OF RGMOVAL Olt <br /> K 5,`l(} CLOSURE'IN PLACE <br /> V 7 <br /> r <br /> 7 U O <br /> N - S <br /> F K <br /> 0 <br /> TI IIS FORM ItAS BEEN COMP 11 J <br /> LE1?'ID UNDER PENALTY OF II AND TO'I BEST OF MY KNOWLEDGP�IS TRUE AND COIi7UiCT. <br /> NAME <br /> J111CIs'USII"ONLY 17I LE <br /> DATE <br /> SWGpTSN WMPM LOCWDGDIS.I'CHUGNAC17Vli I1G'1' 00CGMP1'UG'I' NC � <br /> LGSIiU UG'I' SWL'L•151'IiGM/SUU CODE <br /> un'rl: <br /> I!H 21 044/1211 <br />