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Underground Sto a Tank Program - Farm Tandlifo 71tiop Form FACILITY/SITE INFORMATION(Complete this form for each FARM'TANK locationly F FARM or BUSINESS NA + CONTACT NAME I .�.; A u V1 t Yl C ADDRESS(Street address of TANK location) _>> PHONt#' ';(with-area code) L �� - O , ) ? 1 C �1.1 q.) Lf V I j rl S 1 CITY STATE ZIP CODE NEAREST CROSS snEin- Y V=" CHECK HERE if this ADDRESS should be used for legal Notification OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) O NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS /' OPERATOR PIIONE H (with arca code) R A T CITY STATE I ZIP CODE O R CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete If different from above.) NAME OWN HR CONTACT NAME O NMAILING or STREET ADDRESS OWNER PHONE N(with area code) E R CITY STA'IT I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX .1, ACTIVE.FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y P EXEMPT FARM TANK Sl'1'I; (ALL underground•TANKS at site = to or < 1,100 gallon capacity) E PERMANENTLY CLOSED FARMTANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if needed.) T TANK SI.ZI3 CHEMICALS STORED EsTIMAIP.D DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR A (GALLONS) CURRENTLY Olt PREVIOUSLY IF CURRE I'LY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N I N F O THIS FORM HAS BEEN C MPLETED UNDER PENALTY OF PERJURY,AND TO Till-,BEST OF MY KNOWLEDGE:,IS TRUE AND CORRECT. N NAME TITLE l, V1 .) DA•r1i - 01rFlQi SE ONLY t / SWEEPS N COMPO IAC CODE DISI'CODE NACI'IVE UGT N EXEMPT UGT N CLOSi:D UGT SWEEPS PItGM/SUB CODE DATE J EH 23 044(12/88)