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Underground St,,,ige Tank Program - Farm Tai.Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME L CONTACT NAME <br /> A n Y' 1 tr <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 3 <br /> I � e Gh.� r zo - �' •- � <br /> L <br /> I CITYSTATE ZIP CODE I NEAREST CROSSSTREAT <br /> T � � 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 /> O NAME } OPERATOR CONTACT NAME <br /> P <br /> V—1 -- (P;' <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> Re <br /> TCITY STATE ZIP CODE - - <br /> 1_�Nc �v Coo, 76 <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 /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> •I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y PT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <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 SIZE 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 /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM B OMP Fit PENALTY OF PERJURY,AND TOBEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME ` TITLE 'ffapj 7 DATE <� <br /> OFFICE US NLY <br /> SWEEPS M I OOMP N I LOC CODE DIST CODE#ACTIVE UGT I#EXEMPT UGT J#CLOSED UGT SWEEPS PRGMISUB CODE DATE <br /> EH 23 044(12/88) <br />