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Knderground Storage Tank Program - Farm TanMenformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A GOE NLU7"} �'� b <br /> C ADDRESS Street address of TANK location) ONE# (with area code) <br /> I CITY STATE ZIP CODENEAR � T CROSS STREET <br /> T f ��I s� d /l ' w a)PAIER <br /> Y CHECK HERE if this ADDRESS should c used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE N (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> R I CHECK HERE is this ADDRESS should be used for Legal Notification, <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(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 /> ,l, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> YP EXEMPT'FARM TANK SITE (ALL underB round TANKS at site = to or < 1,100 gallon capacity) <br /> 'jf <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 STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENI'LY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> 110a C) N E F <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLIKTED UNDER PEN TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGK IS TRUE AND CORRECT. <br /> NAME TITLE DATE / I <br /> OFFICE USE ONLY <br /> SWEEPS# COMP M LOC CODE DIST CODE q ACTIVE UG'1' M EXEMPT U(iT N CLOSED UG1' SWEEPS PAGM/SUB CODE DATE <br /> P"91 044(12/88) <br />