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Underground Stor •e Tank Program - Farm Tant iformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A dW&Va Q- <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> L /T9 D S• �r3 ) o <br /> I CITY STATE I ZIP CODE I NEAREST CR/O S FET <br /> T 4 h+- 3 3 .-rTYf a" G' <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area tale) <br /> R <br /> TCITY STATE ZIP CODE ���rj I( _ <br /> O G�V <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. ^r, <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) r <br /> NAME OWNER CONTACT NAME <br /> O <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> YEXEMPT 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 SIZECHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATEOP REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLATE <br /> AT <br /> N 6-- .2161- 9 / — — 00 <br /> K 000 was e, <br /> I <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 ' T71LEDA71; <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODE DIST CODG#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />