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Underground Storage Tank Program - Farm Tank"rnformation Form <br /> FACILITYISITE INFORMATION (Complete this form for each FARM TANK location.) <br /> A F oor B NESS N/Z C CONTACT NAME <br /> D�t7 �O e4r <br /> C ADDRESS(Street addre f TANK locati n PHONE# (with area code) <br /> I C+=•�) 'E ZDE� NEA/RT(JCROSS STREET <br /> T /�lJd� f'G!J <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 /> 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 I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .1. 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 700-0 9 S , /J£ — 7 — / �,tGIJ(/4 (O— C c7 '8!F <br /> 1 2000 i Es EL - 2D --6 F -8 <br /> N <br /> F <br /> O <br /> THIS FORM BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> ,jt <br /> NAME TITLE DATE 1-7—,3-(f <br /> J� <br /> OFFICE USE ONLY <br /> SWEEPS# I CbMP# LOC CODE DIST CODE#ACrIVE 11GT #EXEMPT UG'I' #CLOSED UGT S WEGPS PRGM/SUB CODE I DATE <br /> EH 23 044(12188) <br />