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�^t,formatl0n Form <br /> FACILITY/SITE INFOI2MAg7fi&mplete this Corm for each FARM TANI ton.) <br /> KA <br /> FARMUSINESS NAME <br /> Nor <br /> CONTACT NAME <br /> (Street addrcsa of TANK location) PHONE# (witharcacode) <br /> E ZIPCODE NEAREST CRrry <br /> OSS S11tEE'/'HECK HERE if thio ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete IClnformatlon different from above.) <br /> 0 NAME <br /> p 01'ERA"fOIt CONTACT NAME <br /> E MAILING or STRECT ADDRESS <br /> R OPERATOR PHONE N (with arca code) <br /> A <br /> T CITY STATE v ncppn <br /> O <br /> R CHECK HERE u th o ADDRESS should be used <br /> PROPERTY OWNER INFORMATION&ADDM, 5 <br /> E <br /> ADDRESS <br /> STATE se <br /> C e1C1c ;- c� �e tirr y <Jte ,l <br /> if this ADDRESS should be user <br /> CHECK APPROPRIATE BOX �tlC� a��` :rr, tr_ Il1.i.'; itr, 1C , <br /> \eel y I� l: <br /> T ACTIVEFARM TANK STTE <br /> Y <br /> P EXEMPT FARM TANK SITE <br /> E PERMANENTLY CLOSED FARM TANK S11 Y) <br /> UNDERGROUND TANK INFORMATION(List additlol <br /> T TANKS= <br /> /��o nCnH�.E..M� ICALS STORED ESI1M <br /> N (OAL.ONS) aMAWfILY OR PREVIOUSLY IP C <br /> AL Olt <br /> K ACE <br /> I <br /> N <br /> F <br /> 0 <br /> TIUS PORM HAS DEEM COMPLRI'Ep UNDER PENALTY OI <br /> NAME cr. <br /> OFF1C$USE ONLY <br /> Z23COMP Y LOC CODEDIST CODE Y ACI1VE UGT Y U(EMP1'UCr Y CLOSED UGT SW rLLYS PRGMSUIi COWB (12!88) <br />