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CIL <br /> Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FAI?rM or BUSINESS NAME CONTACT NAME <br /> A dC& r- hug/� e,u a c'L <br /> C DRESS(Street address of TANK location) PHONB# (with area code) <br /> I L.- at�� 2i 10 S'- <br /> L <br /> )PITY- STATE ZIP CODE NEAREST CROSS S'1REET <br /> T 1\/ 7OA� - 3G /il .Ct OCi <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if Information different from above.) <br /> N --- -- <br /> p�, -�"• - . - - -= -_ 01'HItA'I'Olt CONTACT'NOMI <br /> 0 -• ) <br /> P e II f( //C' G C <br /> I- I MAILING or STREET ADDRESS OPERATOR PRONE# (with area code) <br /> R <br /> A <br /> .T CITY STATE ZIP CODE <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> N /\ �Q L o`- �'//.�'i fi ' f�- f{PL[ L'e� OWNER CONTACT NAME <br /> O � <br /> NMAILING or STREFT ADDRESS OWNER PHONE#(with area code) <br /> E .� —So /� f` .fie 20 %'- /- 7 <br /> R CITY) nATE ZIP CODE <br /> ' '5-I <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,I. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> p EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in placc) <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 /> y x D /�1DIJ� e;n0L)e/1 -bee-- <br /> "0 <br /> bee <br /> I <br /> N <br /> F <br /> 01 i <br /> nUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TILE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME _c.c - 17TLE �L(MZ ti CF ��=s �l3 -¢ ' DATE- <br /> OFFICE <br /> ATEOFFICE USE ONLY <br /> SWE.PPSM I COMPY f.GC CODE D6"f C.oDE M ACI7VE UGT YEXEMPT UGI' #CLOSED UGT SWEEPS PIIGM/SUB CODE DATIi <br /> L'H 23 044 (12/88) <br />