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,AN JLrtiUU1N LUCAL HEALTH DISTPICT <br /> UNDERUNDERORO 'ORA6E TANK PROGRAM..- FARM TANK IHFORMATI '_'.M- N O V j G jQ89 <br /> FACILITYIS17E INFORMATION (Complete this Fon for each FARM TANK location) ENVIRQN,MENTA F ' T <br /> FARM or BUSINESS NAME <br /> CONTACT NAME rtl�,,Vllrl E, ViCL.5 <br /> F ---J() /�✓t , �l/�°1/� C !i' <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 ■r*r "CA eooa <br /> Y CITY ST E IIP_ CODE NEAREST CROSS STREETJ _ <br /> l � C E <br /> CNECE NINE if this ADiRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH AN" cooc <br /> k <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> k <br /> tHICL MILE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Complete If Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH w•cA cooc <br /> W <br /> N <br /> E <br /> R CITY SIAfE IIP CODE <br /> CNECE NEIE if this ADDRESS should be used for Legal Notification <br /> CAfct Afpofridtm Nox <br /> T ACTIVE FARM TANK SITE (One or bore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EIEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <br /> PERMANENTLY CLOSED FARM LANK SITE ., (ALL underground TANKS at site reaoved or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank information on separate sheet it 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 EhPIY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> N <br /> f <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME // �� TITLE 0 -4-*' V—"- <br /> DATE <br /> Off E NSE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CuDE 1 ACTIVE UGT 1 EXEMPT UGI 1 CLOSED UGT SWEEPS PREM/SUB CODE DATE <br /> Ell 22 091 (12/88) TA'ZX ��� ���7dvG// //V % %� <br /> IsE� ey TtiF <br />