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Underground Stege Tank Program - Farm Tan. nformation Form <br /> -FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A c r z <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I (� ( /CK !2 �O C� � ' �SOG <br /> L O <br /> I CITY STATE I ZIP CODE I NEAREST CROSS STREET <br /> Y CHECK HERE if this ADDRESS should he 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 /> 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 /> 0 <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 /> T 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 gallon 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 /> uiu <br /> I <br /> N <br /> F <br /> O <br /> 1 1 <br /> THIS FORM HAS BEEN COMPL D UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE.AND CORRECT. <br /> NAME TTT[.E U �, ���.,,L„ DATE -fj <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# I IOC CODE DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGmr.UB CODE DATE <br /> EH 23 044(12/88) <br />