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Underground St,-'age Tank Program - Farm Tay Information F <br /> PACILITYI5I'1'E INFORMATION (Complete this form for each FARM TANK location.) ^/O ' <br /> F <br /> FARM or BUSINESS NAME CONTACT'NAME J�/� 198 <br /> C ADDRESS(Street add�ss of TANK Location) PHONE# (with area Ogd/e) i, <br /> I <br /> CITY S'fAT'E ZIP CODE NFAR ST CROSS STREET <br /> T <br /> Y CHECK HNU,if Btis ADDRGSS should be used for Legal Notification <br /> OPrItATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET AllDRG55 <br /> R OPERATOR PHONE 8 (with area code) <br /> A <br /> T CITY ST'A'f[ ZIP CODE <br /> 0 <br /> R (I IECK HERE is this ADDRESS should he used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 'EA4 1'A21 7 / <br /> NMAILING or STREET ADDRESS OWNER PHONE k(with area code) <br /> E ; <br /> R CITY STATE ZIP CODE <br /> CIIECK HERI:if This ADDIiISS 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 <br /> P EXEMPTFARM 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 sheet if needed.) <br /> T TANKSIZIi CHEMICALS STORED ESTIMATED DATTI LAST USED MfiTIIODOFCI.OSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY Olt PREVIOUSLY IF CURRERILY EMPTY IF PERMANENTLY CLOSED CLOSURE:IN PLACE <br /> N <br /> K - E <br /> N <br /> F <br /> O <br /> TAPS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERI URY,AND 1-0 T11 F.BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAM . TITLE DATL <br /> OFFICE I E ONLY <br /> SWIiP.PSp COMI'a L(X7 COIJit D15'I'CODES gAC'I'IVIi INTI' MIiX1iMP'I'lJ(�1' MCIOSLDIJGT SWEEPS PRGMSUB CODE DATE <br /> HI 123 044(12/88) <br />