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Undergrounrl 5 ---c Tank Program - Farm tc "-)formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> I. FARM or BIJSI ESS NAME �QNTA NAME �(S' <br /> C ADDRFSS/(Street address of TANK locytion) PI ONE N (with area code) <br /> � S 3 <br /> I C17 ---[ ATE LIP CODE NI AfieST CROSS STR •ET <br /> T <br /> Y Cl1ECK 11ERE if This ADDRESS should be used for 1<gal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAM' OPERATOR CONTACT NAME <br /> P i <br /> E MAILING or STREET ADDRESS 9PERATOPHONE N (with area code) <br /> T CITY zIP cone <br /> G <br /> R CI IECK I IERE is this ADDRESS should be used for Legal Notification. 990 <br /> PROPLRTY OWNER INFORMATION &ADDRESS (Complete if different from abo'eVIRoFR vONMEN1 HEA(r <br /> NA OWNER CONTACT NAME <br /> O L <br /> W MAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> N QpcLr,4-ivr <br /> E <br /> R CI'IY STATE ZIP CODE <br /> CIjEcK HERE if this ADDRESS should be used for Icgal Notification <br /> CHECK APPROPRIATE BOX <br /> T AC77VE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> p EXEMPT FARM TANK SI77? (Ala,underground TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SITE (AI,I.undergroundTANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (I.Ist additional tank Information on separate street if needed.) <br /> T TANKSIZE CULMICAISSfORED FSTIMAIIO DAIII IASftSED METIIODOFCLOSUHE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY Olt PREVIOUSLY IFCIIRREND.YEMP"I'Y IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K "7�c� ��So/a�.tz S <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM 11 C 1 .EYED UNDER PENALTY OF PERJURY,AND TO TILE aGSTOF MY KNOWLEDGE,IS TRITE AND CORRECT. <br /> NAME K '1'I'TLe .ICES'/ ATE7177f7. <br /> OFFIC E t1SE ONLY z 5--?-000 <br /> SWEEPS# CAMP# IOCCODG DISTCODENACI'IVEtKiT NID(EMPTt1G7' #CLOSED UGT I SWEEPS PRGMISUD CODE DATE <br /> 1:1123 044(12/88) <br />