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Underground Stmge Tank Program - Farm Tanfcinformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACTtNAME E,RR�c..Rl� <br /> A 3 � Nc}\ S <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 121315 N, JRt"s RD Z� 334-93U <br /> L <br /> 1 CI"I'Y STATE I ZIPCODE I NEAREST CROSS STREET <br /> T I CAL %-a WL Wool) 6 �Q�•_ P..D <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 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE LIP CODE <br /> O <br /> R CHECKHERE 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 /> O <br /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY A'fE 'LIP 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 /> Y EXEMPT FARM TANK SITE ( 8 6 capacity) <br /> F ALL underground TANKS at site = to or < 1,100 gallon ca acil <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 SIZF CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K 000 G S 11—g <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE Q-0 V�eDATE <br /> OFFICE U E L <br /> SW[:EPS# ODMP# LOC CODE DIST CODE N ACTIVE UG I #EXEMPT UG'I' #CLOSED UG4 SWEEPS PRUM'SUB CODE DATE <br /> EH 23 044(12/88) <br />