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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CON"l'ACf NAME <br /> 1 <br /> C ADDRESS(Strut addreu of TANK location) PIIONE A (with arca vale) <br /> ' <br /> L <br /> I CITY STATE ZIP CODE I NEAREST CROSS S'IRLGI' <br /> T <br /> Y CHECK HERE If this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete If Informution different from above.) <br /> O N 01'LRKIOIt CON"PAC f NAML <br /> P <br /> E MAILING or STREETADDRESS OPERKTOR PIIONL N (wilh arca code) <br /> R <br /> A <br /> T CITY 5fA"I'L' 'LII'COD!? <br /> O <br /> It CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete Indifferent from above.) <br /> NAME OWNER CONTACI'NAM l i <br /> 0 <br /> N Nre <br /> MAILING or STREET ADDRESS OWNER HIONE (withaacode) <br /> E <br /> R CITY STATE 1 ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T II ACIIVE FARM TANK SI"!'E (One or more underground TANKS > 1,100 gallon capacity) <br /> VI <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 SPORED FSTIMATID DAIM LAST USW MGI710DOFCl.OSURL DATL'01;I/LMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CUIULENILY EMPTY IF PLRMANFN'ILY CLOSED CUASURU IN I'LACk <br /> N <br /> K <br /> I DD kboot, <br /> N <br /> F <br /> O <br /> T1US FORM HAS BEEN COMPLETED UNDER PENALTY OF YEW URY,AND TO T1lE OFST OF MY KNOWLEDGE; IS TRUE AND CORRI':CI'. <br /> NAME 'ITTLE DATE �— <br /> OFFICE USE ONLY <br /> SWUlInt ODMPY LOCCODL' DISI-CODEaAC11VLU(1'1' #IALNWI'UGlaW-ciLD UG'1 SwllLm I,I(GM/9UD COUIi UA'lli <br />