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y Underground Storage Tank Program - Farm Tank Normation Form <br /> g <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM'I'ANK location.) <br /> F FARM or BUSINESS NAME CONTACF N�AyM�E <br /> yCk. <br /> 42_1 <br /> C ADDRESS(Street addre$ of TANK location)_ PI ZONE# (with area code) <br /> I CITY STATE ZIP CODE I N- EST CROSS S'1RI:E:"T'�f <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPE RATORCONT'ACI'NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE ZIP CODE <br /> 0 <br /> R CHECK HERE is this ADDRESS should be used ror Legal Notification. <br /> PROPERTY OWNER INFoRMA'1'ION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACTNAME <br /> 0 _ <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY ' STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACIIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground'PANICS at site = to or < 1,100 gallon capacity) <br /> EPERMANENTLY CLOSED FARM"TANK SITE (ALL underground TANKS at site removed r closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if needed.) <br /> T TANK SIZE CHEMICAIS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE ATE OF REMOV OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY 1F CURRE-N'I'LY EMP'T'Y IF PERMANEN'T'LY CLOSED LACE <br /> N <br /> K G a,-�, 3-7 <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 TITLE DATE `7 3 <br /> OFFICE USE ONLY <br /> SWEEPS# COMP#i LOC CODF. DIS7'CODE#ACl'TVF UG'1' #T:7CEMPT UGT #CLOSED UGT I SWEEPS PRGM/SUBCODE DA'L'E <br /> Eli 23 044(12/88) <br />