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Underground Slue Tank Program - Farm Tan' nformation Form <br /> FACILITY/SITE INFORMATION (Complete this form foreach FARM TANK location.) <br /> I, FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> C ADDRESS(Street address or TANK location) PHONE k (with arca code) <br /> Ik6rAj Z6 — S <br /> L <br /> l CITY STATE I 'LIP CODE NEARCST CROSS STREET <br /> f saorno i) i e14 <br /> Y CHECK IIERE if[his ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if Information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> Y <br /> F MAILING or STREET ADDRESS OPERATOR PHONE M (with area code) <br /> R <br /> A <br /> T CITY STATE ZIP CODE <br /> O <br /> RCI IECK I IERE is this ADDRESS should be used for Legal Notification. <br /> PRO11LIYTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CON'T'ACT NAME <br /> 0 <br /> W MAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> N <br /> E e?O 6— -2-- <br /> R CITY STATE ZIP CODE <br /> CHECK IIERE if IL 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 ALL under round TANKS al site = to or < 1,100 gallon capacity) <br /> P I:XL•MPTFARM'1'ANKSI71i ( 6 8 P Y) <br /> E PERMANENTLY CLOSED 17ARM TANK SITE (ALT.underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional lank information on separate sheet if needed.) <br /> T 'I'ANKSIZE CIIEMICAISSTORED ESTIMATED DAT(:I ASI'USED MEf110DOFCLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY Olt PREVIOUSLY IF CURRLM1'LY EMP'T'Y IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> N <br /> F <br /> O <br /> 'IRIS FORM HAS BEEN COMPLVIFED UNDER PENALTY OF PERJURY,AND TO'I HE JST OF MY KNOWLEDGE,ISTRUE AND CORRECT. <br /> NAME TITLEIto DATE <br /> OFFICE USE ON . <br /> SWEEPS CDml,0 IOC CODC DIST CODE N ACTIVE UGT #EXEMPT II MCIOSIiD UGT SWEEI5 PIIGM/SUD CODE DATE <br /> 1:1123 044(12/88) <br />