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Underground Storo Tank Program - Farm Tanko'ormation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK loC tion-)ONTACTNAME <br /> F FARM or BUSINESS NAME I'+ <br /> A A D O e ro PHONE# (with area code) <br /> S <br /> C ADDRESS(Street address of TANK location) �A_ /e h <br /> I yC y <br /> (o y 7 G G��i of �f c <br /> L ATE <br /> SZIP CODE NEAREST CROS STREET / <br /> I CITY ��Q C� ���( - (_JG {4 CGG2 <br /> T I-I <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> OPERATOR CONTACT NAME <br /> O NAME QndPI'u ( Su41 �i &(- 0 (,4lQEIb <br /> P r� OPERATO PHONE# (with area code) <br /> E <br /> MAILING or STREET ADDRESS <br /> R `) fV � � � � Al b\ �d <br /> A STATE ZIP CODE <br /> T CITY C4 <br /> used for Legal Notification. <br /> R CHECK HERE is this ADDRESS should be <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from WNER )CONTACT NAME <br /> NAMES// <br /> G FGtCi �l <br /> OWNER PHONE#(with area code) <br /> W MAILING or STREET ADDRESS <br /> N <br /> E STATE ZIP CODE <br /> R CITY <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX ca <br /> ACTIVE FARM TANK SI;r � (One or more underground TANKS > 1,100 gallon P acit <br /> y) <br /> T /?"I (ALL underground TANKS at site = to or < l,l0o gallon capacity) <br /> Y EXEMPT FARM TANK SITE 4x <br /> PALI,underground TANKS at site removed or closed in place) <br /> E PERMANENTLY CLOSED FARM TANK E <br /> UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) DATE OF REMOVAL OR <br /> METHOD OF CLOSURE CLOSURE IN PLACE <br /> T TANK SIZE CHEMICALS STORED FSTIF IF CCURRENTLY EMPTY TED DATE LAST USED IF PERMANENTLY CLOSED <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY RR <br /> N <br /> K <br /> I <br /> N <br /> F <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TIIF.REST OF MY KNOWLEDGE, <br /> IS TRUEATB CORRECT. <br /> O <br /> TITLE 0 kr 11 ( { J <br /> NAME L<<" ✓ " c c <br /> OFFICE USE ONLYDATE <br /> SWEEPS# COMP# LOC CODE DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PAGM/SUB CODE <br /> EH 23 044(12/88) <br />