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anN OAAU1N LUCAL HEALTH DI•RICT <br /> punERGROUun STORAGE ... • OGRAM FARM TANK rNrnowa <br /> FACILITY/BITE INFORMATION (Coeplete this Form for each FARM TANK location) FO <br /> FARM or BUSINESS NAME <br /> CONTACT NAME <br /> F w _ 151 <br /> R / <br /> A !� A9 Fi Gia s <br /> C ADDRES (Str et address of TANK location) <br /> I PHONE t MIT ARRA coos <br /> I �' M! t�OA) 20 1f6 -Co 7 /3 <br /> T CITY STA E ZIP CODE NEAREST CROSS STREET <br /> Y <br /> �3 G VC —7—e A,' � O I' aut�C swJ <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION It ADDRESS (Complete if Information Different from Above) <br /> NAME <br /> Qn_ OPERATOR CONTACT NAME <br /> , l9 <br /> P <br /> 0 G— s�yS / c[1 /� / <br /> eU ! G�°✓� <br /> E MA[LIN S REET ADDRESS <br /> R OPERATOR E t WITH ARIA cocc <br /> A 5 M� ! ti) �� . <br /> T 2L1a2- Co l /3 <br /> 0 CITY ATE ZIP CODE <br /> R �� Z '!G <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION Z ADDRESS (Complete if Different from Above) <br /> NAME <br /> OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRE55 <br /> N OWNER PHONE t WITH AA(A CCDQ <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should 6e used for Legal Notification <br /> Checl Appropriate lox <br /> TQPEXEMPT <br /> CTIVE FARM TANK SITE (One or Gore underground TANKS ) 1,100 gal. capacity) <br /> FARM TANK SITE (ALL under round TANKS at site a g to or ( 1,100 gal. capacity) <br /> ERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at sit removed r closed in place) <br /> 11 111 <br /> UNDERGROUND TANK INFORMATION (List Additional tank information on separate sheet if needed) <br /> T TANK SIIE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> N (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K �5P <br /> I r /ta k <br /> F <br /> 0 <br /> THIS FORM HAS B EN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME <br /> TITLE GATE <br /> OFFICE USE 0R <br /> SWEEPS OMP t LOC CODE DIST COOS i ACTIVE UGT t EXEMPT UGi t CLOSED UGT SWEEPS PRGM/SUB CODE OA1E <br /> EH 23 044 (12/88) <br />