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Underground Stole Tank Program - Farm Tanloformation Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT'NAME A d C o 86hEJ (1- J; o C ADDRESS(Street address of TANK location) PHONE# (with area code) - I L — //p J� ` c' c✓��J� I CITY STATE ZIP CODE I NEAREST CROSS STREET T f, i,v d i5>v CCA SR 3 (- Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) 0 NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) . R A T CITY STATE I ZIP CODE O R CHECK HERE is this ADDRESS should he used for Legal Notification. PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) NAME OWNER CONTACT NAME 0 NMAILING or STREET ADDRESS OWNER PHONE#(with area code) E R CITY STATE ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX ,I. ACIIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) P t E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OP REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K L2 '1` I N F O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME RTC,'U A R,1 1;N I TITLE MA Aj A fL DATE? OFFICE USE ONLY SWEEPS# COMP N LOC CODE DIST CODE#ACTIVE UGT I#EXEMPT UGT #CLOSED UGT I SWEEPS PROMAUB CODE DATE EH 23 044(12/88)