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Underground Stor ! Tank Program - Farm Tank formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUS FSS NAME CONTACT NAME <br /> A &I d rrt v R/o SR. <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> L /. w 1J d Q ,f o5— <br /> CITY // STATE ZIP CODE NEAREST CROSS STREET / <br /> T SToc�fo C 9 20- E /2T / ! le /la . <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 NAME OPERATOR CONTACT NAME <br /> P c Rk FrinS S . <br /> D <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> A 9O 1-17 2-02- LL 3605 <br /> T CITY // STATE ZIP CODE <br /> G sides (f4 . 73-236- <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 CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHFCK 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 <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 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 HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME ,.c, 17TLE DATE 7 9 r- <br /> OFFICF,USE ONLY <br /> SWEEPS# COMP# IAC CODE I DIST CODE#ACTIVE UGT I#EXEMPTUGT #CLOSEDUGT I SWEEPS PRGM/SUBCODE DATE <br /> EH 23 044(12/88) <br />