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Underground St(,. ,ge Tank Program - Farm Tany:nformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS CONTACT NAME <br /> A tq /L <br /> C ADDRESS(Stte�L�d of TANK location) ON1� ith area code) <br /> L 1 �/ Ltd q �) _ 2 Ex 1-t <br /> I CITY S iE -"zn DE - NEARES CROSS EET <br /> T J , C c.7Z SJ 4410 o , <br /> Y CHECK HERE if this ADDRESS should be aged for Legal Notif cation <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# (with area code) <br /> R <br /> A <br /> T CITY STATE I 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 /> NAME OWNER CONTACT NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <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 /> .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 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 /> K r 3 <br /> I f <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME. — — TITLE < DATE d <br /> OFFICE ONLY <br /> SWEEPS# ODMP# LOC CODE I DIST CODEJ*ACTIVE UGT I#EXEMPT UGT #CLOSED UGT I SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />