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Underground Storage Tank Program - Farm Tank hr[ormation Form <br /> FACILITYISITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACTNAME <br /> A <br /> C ADDRESS(Street address of TANK location) PHONE M (with area code) <br /> I <br /> L <br /> I CITY PSTATE ZIP CODE NEAREST CROSS STR_ EEf <br /> T ` <br /> YI CHE K HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDR&S3 (Complete If Information different from above.) <br /> 0 NAME OPERA'T'OR CONTACT NAME <br /> P 1oc 1 6, V, f <br /> E MMUNOorSfREETADDRESS OPERATOR PIIONEM (with area code) <br /> R A e <br /> A t — <br /> T I STATE I 'LIP CODE <br /> o <br /> RI CHECK HERE Is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME <br /> (/u�� OWNER CONTACTNAME <br /> O —^ t �✓- C- .� G.Jclr.C'.&0 <br /> NMAILING or STREET ADDRESS OWNER PHONE M(with area code) <br /> E A u e 3- <br /> R CITY / SP/ATE ZIP CODE <br /> G C_I U <br /> CHECK HERB if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .I. ACIIVE PARM 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 CLOSE FARM TANK S TE (ALL underground TANKS at site removed or close i lace) <br /> k � "w <br /> UNDERGROUND TANK INFORMATION(List additional tank"2fia'n'0no ie ars sleet if o y3 ed.) 20 � <br /> T TANKSMB CHEMICALS STORED ES71MATED DATE LAST USED MMMODOFCLOSURE DATE OF IIEMOVAI_Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANFN LY CLOSED CL OSUIW IN PLACE <br /> N <br /> K /O 000 3 <br /> i o 7 <br /> N <br /> F <br /> 0 <br /> TIUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE+BEST OF MY KNOWLEDGE IS TRUE AND CORRRCI'. <br /> NAME _ - TITLE DATE <br /> OFFICE USE ONLY <br /> swum COMPS LDCOODEDISfcODESACHVELIG'f I sEXEMPTLG'1' MCLUSEUUaI' I SWEEPSPRUM/SUUcOUE UA'I'li <br /> EH 23 044(1T/88) <br />