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Underground Soge Tank Program - Farm Ta%nformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CO Cr NAME <br /> A e ( _ <br /> C ADDRESS(Street address of TANK location) H NEN (with aarea code) <br /> L <br /> I CI STATE I ZIP CODE NEAREST CROSS STREET <br /> T efi- Ems¢ // <br /> Y VCHECK 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 N (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> R CHECK HERE is this ADDRESS should he used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME 0 C NTACT NAME <br /> NMAILING or STREWADDRESS 0 R PHONE N(with area code) <br /> E c, S,-, . -_ <br /> R CITY S TE ZIP CODE <br /> �Q <br /> iECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( B B capacity) <br /> P A[.I,underground TANKS at site = to or < 1,100 gallon ca acit <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALI.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 /> i <br /> K <br /> 1 kO,)C <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME <br /> C� t,Z'�� �e-�_c�e�� TITLE ���L, �-�,e J- 1�X�/ DATE <br /> OFFICE USE ONLY <br /> SWEEPS H COMP N IOC CODE I DIST CODE N ACTIVE UGT N EXEMPT UGT N CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />