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Underground Storage Tank Program - Farm Tank Information Form <br /> FAC_LITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT N ge <br /> C ADDRESS(Street addrita of TANK location) PIIONEN (wit4Zcode) <br /> 1 /437. S C*�fdltail/ ��y,,. 2r <br /> L <br /> I 19,5� T ii <br /> CITY SLATE ZlP CODE NEAREST CROSS S'TRLEI ')F , <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> 0NAM OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREEP ADDRESSOPERATOR PI ZONE N (with arca code) <br /> R <br /> A <br /> T CITY STATE 'LIP CODE <br /> 0 <br /> R L CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER com'ACrNAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> E <br /> R CITY STATE 1 ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for legal Notification <br /> CHECK APPROPRIATE BOX <br /> .1. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground'TANKS at site = to or < 1,100 gallon capacity) <br /> A <br /> 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 CREMICAIS STORED ESTIMATED DATE LASTUSED MM: IOD OF CLOSURE DA'I'S OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CWSURI:IN PLACE <br /> N <br /> K UO r ,-... gc� <br /> I <br /> N <br /> F <br /> O <br /> TIUSFORM IL<S BEEN CO LEM UNDER PENALTY OF PERJURY,ANDTOTILE BESTOF MY KNOWLEDGE,IS TRUE AND CORRF.Ur. <br /> NAME i ! l` - "TITLE DATE <br /> OFFICE USE ONLY <br /> SWEEPS ODMPN 11X:CODE I DISI'CODE N ACII VE LKA NEXEMPI UG'10CLOSED UO"I S WhEl'S 11RGM/%UD COL)h UA'lli <br /> EH 23 044(121M) <br />