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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK locution.) <br /> F FARM or BUSINESS NAME CONTACT'NAME <br /> A Cdd lv. I y-z - <br /> C ADDRESS(SDeot atklmrr of TANK location) PHONEY (with area code) <br /> L �`✓.1"i C; �t. 4U`� P. .){%� <br /> I CITY STATE ZIP CODE I NEAItI•S"f CI(OSS S'11t6fa' <br /> T — - <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete If Informutlon different from above.) <br /> O NAME OPERA'fORCONTACI'NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERA'I'OR PI LONG N (with arca code) <br /> R <br /> A <br /> T CITY STATE I 'LIP CODE <br /> O <br /> R I CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACI'NAME <br /> 0 <br /> NMA1LN0 orSTREf STREET ADDRESS OWNER NIONE 0(with area code) <br /> E <br /> R CITY STATE I 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 <br /> P EXEMPT FARM TANK SITE (All.underground TANKS at site = to or < 1,100 gallon rapacity) <br /> PERMANENTLY CLOSED FARM TANK SITE (All.underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional lank Information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USLD mimictDOFCLasune DATE OI'I(F.MOVA_OI( <br /> A (GALLONS) CURRIWILY OR PREVIOUSLY IF CUR1lE14111-Y EMP'T'Y IF PEIIMANIEWILY CLOSED CI.O.SUM:IN 1'UCIi <br /> N <br /> K Pc_,1cz <br /> F 5 <br /> -co <br /> %.c5r <br /> cti o rAS <br /> O a - <br /> TIES FORA{HM BM COWLRM UNDER PENALTY OF PERUUIIY,AND TO TILE UFST OF MY KNOWLLDGI,"IS TRUE AND CORRRCT. <br /> NAME 5' _ Lc= 'I7TLE r DAIV. <br /> OFFICE USE ONLY <br /> SWLiEPSY I ODMPM LOCCODE DIS'I'CODESACIIVI:UU'Is1i W?I'UGI' aC"L•DDO'I T <br /> SWLLI'i I'IIGM/SUU CODE DAM. <br />