Laserfiche WebLink
Underground Stof'3ge Tank Program - Farm Tank information Form <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NA� CONTACT NAME <br /> A <br /> C ADDRESS(Street addrgss of TANK locatiea}_ PHONE# (with area code) <br /> L <br /> CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T �— <br /> Y HECK 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 code) <br /> R <br /> TCITY STATE I ZIP CODE <br /> O <br /> RCHECK 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 /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <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 /> ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g g capacity) <br /> P ALL underground TANKS at site = to or < 1,100 anon ca acit <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 /> 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/':; .- ,�, ,, '� TITLE _ DATE -j <br /> OFFICE USE ONLY <br /> SWEEPS COMP# LOC CODE I DIST CODE#ACTIVE IIGT #EXEMPT UGC 1#CLOSED UGT I SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12188) <br />