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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTA�CCj17 NAME <br /> C ADDRESS(Slreeladdic"ofTANKlocation) I'IIONBM (withareacode) <br /> L <br /> I CITY >> STATE �aZIP CODE NFA�1t/FS'r CROSS S'11WEN' <br /> T 0-k& J ,n /s? — /, •/w <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if Information different from above.) <br /> 0 NAM011LIMI'ORCON•rA(:I'NAMG <br /> P 3&- /)�P CS a6dV-P— <br /> E MAKING or STREETADDRESS OPBI(A•I'OR PHONE M (with arca axle) <br /> R <br /> A <br /> T CITY STA'1'L I •LIP CODL <br /> O <br /> RCHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME O WN LR CONT'ACI'NAMI i <br /> O <br /> N (.::,/LING or ShEhTADG S OWNLR PHONE B(with area code) <br /> v - <br /> E L <br /> R CITY STA ZIP CODE <br /> CHECK HERE if this ADDRESS should be tvicd or Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .I' 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 /> E / PERMANENTLY CLOSED FARM TANK SITE (ALL underground'rANKS 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 EsTwAT ED DATE L. "f usw mi:n IOD OF CLOSUHU DA'I'U OP RLMOVAL OR <br /> A (oALIANS) CURRENTLY OR PREVIOUSLY IF CURILENILY EMP•1'Y IF PLRMANFN'lLY CRUD CL[r.4URE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE UST OF MY KNOWLELGK IS TRUE AFIU COKICE-ul'. <br /> NAME 'rITLE DME <br /> OFFICE USE ONLY <br /> Swufips s ODMP Y IAC CODE DLS•I'CODE s ACIIVL UO'Is L XLiMPT UG'I' Y CLOSLiD UG'I' SWLhPS I'ILGMISUU CODIi DA I L <br /> rnt oa nee norart, <br />