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Underground St Ige Tank Program - Farm Tal Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A �L( bh& 1)N I f-U P 9 plC <br /> C ADDRESS(Street address of TANK location <br /> I f2666 n /� ) PHONEN (withueecode) LO�j_tfrs[_5-� <br /> L C�Pian�C� !`� "Z -(u <br /> I CI STATE ZIP CODE NEAREST CROSS STREET <br /> Tfo fF iI `" 0 Z/ T i°U ✓/C <br /> Y e <br /> CHECK HERE if this ADDRESS should be uscd for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete Irinrormatlon different from above.) <br /> O N <br /> OPERATOR CONTACT NAME <br /> F MAl l LNG or STREET ADDRCSS OPERATOR PHONE N (with area code) <br /> R 2 30 %,' vim �4y/, /e zrx,-ami s �/� <br /> A Lo9-/iso G Zz�i <br /> T CIN SCA'L'E ZIP CODE <br /> o sfac�fv`r !=qtr 75 21:� <br /> R CHFCK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> 0 AM OWNERCONTACCNAME <br /> / q <br /> NMAILING or STREET ADDRESS 1 OWNER PHONE N(with area code) <br /> F � /4-we- <br /> [R <br /> /w e / <br /> R CITY STATE ZIP CODE <br /> CHECK IIFEiF if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site a to or < 1,100 gallon capacity) <br /> F 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 M171TIOD OF CIASURR DATE OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANFNILY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> N <br /> F <br /> O <br /> THIS FORM EN COMPL. UND R PENALTY OF PFR111RY,AND 7'0 TILE REST OF MY KNOWLEDGE,IS TRUE AND CORRFX7r. <br /> N s TITLE <br /> DATE - U. <br /> O1+PICT?USP ONI,V <br /> SWEI75M MMPI IAC CODE UIS'L'CODEaACIIVEIIG"I' NI:KFIdPI'UGI' MCWSEDUGT SWEWISPROMISUUCODE UATIi <br /> Ell 23 044(12.188) <br />