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Underground Storage Tank Program - Farm Tank information Form <br /> FACIUTY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> C ADDRESS(Street address of TANK 131 <br /> location) PHONE M (with area code) <br /> L l.Sa <br /> I CITY STATE ZIP CODE I NEAREST CROSS STREET <br /> T f� ,9 fc� /7 CA 7533 , 1 9jc>c ,-% <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERA3OR INFORMATION&ADDRESS (Complete If information differeat from above.) <br /> O NAME <br /> P OPERATOR CONTACT NAME <br /> E MAILING or STREET ADDRESS <br /> R OPERATOR PHONE# (with area code) <br /> A <br /> T CITY STATE j 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 /> :NG <br /> 1w <br /> OWNER CONTACT NAME <br /> 0 <br /> N to STRFT ADDRESS OWNER PHONE#(with arca 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 PERMANFMLY CLOSED FARM TANK SITE <br /> (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 CHEMJCA S STORED —ESTIMATED DATE LAST USED Mg77{OD OF CIURB DATE OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PPRMANENrLY CLOSED CLOSURE IN PLACE <br /> N <br /> K C(,D k Ad0"d <br /> I kIL) c4i-r .r 114 <br /> / <br /> N <br /> F A) 'To r// <br /> 0 <br /> THIS FORM HM BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO 171E BESTOF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE DATE <br /> OFFICE USE ONLY <br /> SWEP.PS Wscomp Y !OC CODE DLST CODE IACME UGT IN EXCHP7'UGC Y CLOSED UOT SWEEPS PRCMrSUU CODL+ DATE <br />