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Underground Stulyge Tank Program - Farm Thr. xinformation Form <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM <br /> ,orrBUSINESS NAME CONTACTNAME <br /> A <br /> C ADDRESS(Sheet address ofTANK location) PHONE s (with area code) <br /> L U—/ <br /> I CITY STATE I ZIPCODE NEAREST CROSS STREET <br /> T / f ( x <br /> Y ClIECKHERE 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 MARINO or STREET ADDRESS OPERATOR PHONE s (with ams code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> 0 <br /> R 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 N(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 (Ona or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> PEX&ff T FARM TANK SITE (ALL underground TANKS at site - to or < 1,100 gallon capacity) <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 shoat If needs.) <br /> T TANKS&M CHEMICALS SMR® BF17MATED DATE LAST ASHD MBIHOD OF CL 0SURE DATE OF REMOVAL OR <br /> A (OAIIANS) CURRENTLY OR PREVIOUSLY IF CURRENILY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K lC <br /> I ry <br /> N <br /> F <br /> 0 <br /> 72M FORM HAS BEEN CObUVUW UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND COMIM. <br /> NAM TITLE DATE <br /> OFFICE USE ONLY <br /> SWEEPSM COMPO jLOCCODEjD13TcOD4#ACnvliu0T #wwmFTuur rcIASEDLjOT SWI mpitOMBuisco E DATE <br /> EH 23 044(IZM) <br />