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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK locution.) <br /> F FARM or BUSINESS NAME I CON"l'ACI'NAME <br /> A ( r h tru fULt✓ ' VLL uU Yl <br /> C Al DDRBSS(Suet addreu of T� ti YIIONE Y 6 q(witharea cafe) <br /> I , "f50 �1 L , , 5 7 L)9 3 -S <br /> L STATE ZIP CODE NEmwsT CROSS S'IHEpa" <br /> 1 CITY <br /> T L� I ��tl ; LJ <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If information different from above.) <br /> O 1 NAME 01'IA/0'ORCONTACI'NAMI'. <br /> P <br /> E MAILING or STREET ADDRESS OPERA"1'OR PI ZONE Y (wish area axk) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> I OWNER CONT'AC'1'NAMIi <br /> G 6J0�d A 1,1T � L <br /> NMAILING orSTRBBTADDRESS OWNER PHONE Y(with area code) <br /> E 5o tlyta <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .1, ACTIVE FARM TANK SITH (One or more underground TANKS > 1,100 gallon capacily) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK siTc (ALL underground TANKS w silt removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List addltional tank Information on sepurate street if needed.) <br /> T TANK SIZE CHEMICALS STORED ISTIMAT'BD DATE LAST USED wn IODOFCLOSUIIE DATE OI:IIEMOVAI.Olt <br /> A (OALUDPLS) CURREMILY OR PREVIOUSLY IF CURRIWILY EMPTY IF PERMANENTLY CL2SCD CL.U.SUIdi IN PLACE <br /> I <br /> N <br /> F <br /> O <br /> 1 1 <br /> THUS YORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TILE BEST OF MY KNOWLEDGE,IS TRUE AND CORRF:Cr. <br /> NAME z! _. ' 711'fLE 7 <br /> OFFICE USE ONLY <br /> SWLiIPSY I C'OMPY L.00CODL' DLS'1•CODEYACIIVLW'IOUXUMPTUG'I' YCLwLDUGf SW11i151•RGMhUU CODti DAM <br />