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Underground Sto,%..Ce Tank Program - Farm Tan1 Tformation Form <br /> 14.0 <br /> FACILITYISITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A Focjica, 1 ( <br /> C ADDRESS(Street address of TA14K location) PHONE# (with area code) <br /> IPe. Box 09- <br /> L <br /> 1 CITY / STATE ZIP CODE NEAREST CROSS STREET <br /> T � O/? 5,3o2 6 rmart O <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 F6t Cf 0Li L <br /> E MAILING or STREET ADDRES9 OPERATOR PHONE# (with area code) <br /> R <br /> A — -- — — <br /> T CITY STATE I ZIP CODE <br /> O <br /> RI CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNERCONTACTNAME <br /> i <br /> G I'o ctJ <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E © aD1-838- Sg`I <br /> R CITY STATE I ZIP CODE <br /> F��Cajon eA• q53.zv <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 (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <br /> I, 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 CL.OSLIRE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY ED CLOSURE IN PLACE <br /> N , <br /> K —, <br /> N <br /> F <br /> O <br /> TUIS FORM Hg�BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THIS BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. <br /> NAME. DATE rl.3 - <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODE DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGMISUB CODE DATE <br /> EH 23 044(12/88) <br />