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Underground Stolle TMfk Program - Farm Tank-rnfornration Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F <br /> A '-.A <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <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 OPiRATORCONTACT NAME <br /> pA.ix CA4 P, PM(Z �CtA A- <br /> E MAILING or STRELTADDRESS OPERATOR PHONE# (with area code) <br /> AFc- . CYC LI kZ<c _ FS 5 S <br /> ,h CITY �STATEZIPO <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 /> c <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE ZIP CODE RECEIVED <br /> CHECK HERE if this ADDRESS should be used for Legal Notification MAY 2 2 1400 <br /> CHECK APPROPRIATE BOX c NV IRON MENTAL H E ALTH <br /> ,L, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y c PT sI T et E ALL underground at site = to or < 1,100 gallon capacity) <br /> P EX.FM. . F.4K... .ANK...:._ ( f 8 P Y) <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 /> K - CS <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM IIAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> � TITL - I—�LNAME <br /> OFFIC USE ONLY <br /> SWEEPS COMP# IAC CODE I DIST CODE#ACTIVE DOT #EXEMPT UGT #CLOSED UGI' SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(121M) <br />