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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME <br /> F _ CONTACT NAME <br /> A iiA:irte ti ht-1 ,- k y� j ,� eU4.4_ <br /> C ADDRESS(Slreel address of TANK location) PHONE M (with area code) <br /> 1 40 d"'Op <br /> L 2�`f— 77j— <br /> I CITY STATE I ZIP CODE NEAREST CROSS S'1REC1' <br /> TC° ��1h �s C`>�1 ��-, 7"q <br /> YI I 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 <br /> E MAILING or STREET ADDRESS OPERATOR PI IONE N (with arca code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> 0 <br /> R CHECK HERE is Ihis ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete If different from above.) <br /> NAME <br /> OWNER W N'1'ACI'NAME <br /> O <br /> IN MAIL1NRIxSTRE6fADDRESS OWNER PHONEY with area code <br /> E I <br /> R CITY STATE LIP CODE <br /> E7 <br /> CHECK HERE if[his ADDRESS should be used for I-egal 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'1'ANKS al site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank Information on separate sheet if needed.) <br /> T TANK SIZ% CREMICAIS STORED ESTIMATED DATE LAST USED MEMOD OF CLOSURE DA'Z'E 01'REMOVAL Olt <br /> A (OAL oNS) CURRENTLY OR PREVIOUSLY IP CURRENTLY EMPTY IF PERMANPN'ILY CLOSED CIASURI'.IN PLACE <br /> N <br /> oZJu �ts� c� t,,1 or/ �y� �c �L�vvdri>l� /�/v✓ �y�^ <br /> I s�i S o< i• /r/d /26'7 A967 /ywJ <br /> N <br /> F <br /> Lo <br /> — <br /> TIES FORM ILLS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TEE RES'I'OF MY KNOWLEDGE IS 7'RUIi ANI)CORRECT'. <br /> NAME - 'HTLE DATI; <br /> OFFICE USE ONLY <br /> SWEEPS N COMP N 1 IOC CODE I DIST CADS N ACD VE UG-I' N Ex EMP,'UO'1' N CLOSW UGI Swua l'5 PRGM/Sub CODE UA I'li <br /> CH 23 044(121881 <br />