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Underground Storage Tank Program - Farm Tank information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A -FR j PL&7 J TA, c K I N G <br /> C ADDRESS(Street address of TANK location) PHONE# (with arca code) <br /> 6, 2 6. d I R cf�T w ;K 'tc� - Cy <br /> L a33 <br /> I CITY STATE 'LIP CODE NEAREST CROSS STREET <br /> T ti1w r�C � CH y� � Lt3THr;c <br /> Y CHECK 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# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> IRI I 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 /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <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 /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FO"HAS BEEN COMPLETED UNDER PE TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME A . I ITLE 1":,11F yr DATE <br /> OFFICF.IJE ONLY t <br /> SWIiEPSN COMPN IACCODL• D13TCODE#ACI'IVL'UGT I#BXEMPT'UG'I' #CLOSEDUGT I SWEEPS PRGMISUB CODE DATE <br /> EH 23 044(12/88) <br />