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Underground Stora Tank Program - Farm Tank Y11ormation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> CONTACTNAME <br /> F FAR or BUSIN S / / <br /> A q21� �1AiLitl,riti 1 G <br /> PHONE# (with area code) <br /> C ADDRESS(Street add7p of ANK locatiop) 9'77 '30f s <br /> L STATE ZIP <br /> CCODE NE/AREST CROSS ST{tEETT <br /> I CITY9536 /( /C�/ <br /> Y HECK 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 /> 0 NAME <br /> P <br /> E MAILING otHFREis <br /> a <br /> E# (with area code) <br /> F. <br /> A CITYSTATE ZIP CODE <br /> T <br /> 0 <br /> R CHDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> OWNER CON'TACf NAME <br /> NAME <br /> 0 <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> T <br /> Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL 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 U REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N /�8 �•uovE �� 7 <br /> K 50�it <br /> I <br /> N - <br /> F <br /> O <br /> T111S FO H .6 N OMP D UNDER ALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAM TITLE DATE 7i 3 9U <br /> OFFICE USE ONLY <br /> ( SWEEPS N CbMP# IDC CODE DIST'CODE#AC:1'IVE 11G'I' #8XEM1''I'UG1' N CLOSED UGI' SWEEPS PRGMfSUB CODE DATE <br />