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Underground Storage Tank Program - Farm TanaTnformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONI'ACI'N <br /> A <br /> C ADDRESS(Simataddress ofTANKlocalipp4�) PIIONEM (wiujqt §wd.) <br /> L 37� .� �fAR°lt�� EN., 2r <br /> L <br /> I CITY STATE ZIPCODE NFAItESrCROSSS'17(fE1'/F1"✓;LqF <br /> MiT tiTq( <br /> T /-SC/9 10J� 75 'r p� /�d <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification S <br /> OPERATOR INFORMATION &ADDRESS (Complete If information different from above.) <br /> 0 NAME / 011E11ATOR CONTACI'NAMG <br /> P L E t l/%i7i <br /> E MAILING or✓STREET ADDRESS/� / OPERATOR PIZONE M (with area code) <br /> T CITY STATE ZIP CODB <br /> R ICHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER COMPACT NAME <br /> 0 <br /> NMAILING or STREETADDRESS OWNER PHONE M(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 /> .I. ACTIVE FARM TANK SPIE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL undcrground TANKS at silo = 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 TANKSIZB CHEMICALS SPORED ESTIMATED DATE LAST USED ML`n IODOFCLASUI(E DATE OF REMOVAL OIL <br /> A (OALLDNS) CURRENCY OR PREVIOUSLY IF CUIOLENILY EMP'T'Y IF PERMANE.N'ILY CLOSED CL.OSUIUi IN PLACE <br /> N <br /> K <br /> I J <br /> N <br /> F <br /> O <br /> TIUS FORM HAS BFR CO LWM UNDER PENALTY OF PERJURY,AND TO TIM BEST OF MY KNOWLEDGE:IS TRUE AND CORRI'.Cr. <br /> 7 <br /> NAME L L 'fITLL DATT•. <br /> OFFICE USE ONLY <br /> SWEEPSM WMPM LOCCODL' DLSI'CODEMACnVLUO"I' I #EXr WTUG'I' MCL05EUUG'I SWELISPRGM/SUUCODI: UA'1'li <br /> EH 23 044(12JU) <br />