Laserfiche WebLink
n SAN .' ,QUIN LOCAL HEALTH DIF 'CT <br /> I(IL UNDER6RD.., STORAGE TANK PROGRAM - FARM TANK INFORMAT`ryM16RM <br /> FACILITY/BITE INFORMATION (Complete this Fore for each FARM TANK location) JAN 1 ; <br /> FARM or BUSINESS NAME CONTACT NAME" `- ''V -' ' ALT <br /> F <br /> A <br /> C ADDRESS (Street address of TANK location) PMOME 1 WITH A.&. COOK <br /> -c / ceog• <br /> ly <br /> CITY 0/ <br /> STATEIIP CODE NEAREST CROSS STREET <br /> CHECK NEVE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 1 ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA ME <br /> R <br /> A <br /> T <br /> 0 CITY STATE " CCODE <br /> R <br /> CHECE NEVE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Complete if Different fro@ Above) <br /> NAME OWNER CONTACT NAME <br /> O MAILING or STREET ADDRESS OWNER PHONE 1 WITH All. COWL <br /> W <br /> N <br /> E <br /> R CITY STATE LIP CODE <br /> CNfCI MENE if this ADDRESS should be used for Legal Notification <br /> Chea Appopriete Box <br /> Y ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site K to or ( 11100 gal. capacity) <br /> E <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL uade.iew;,d TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank information on separate sheet if needed) <br /> T TANK SITE 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 /> 1 n /QCr Y <br /> N ' <br /> F <br /> r 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME , /��4� TITLE DATE <br /> 7 i <br /> OFFICE USE ONLY <br /> EP1 LOC CODE DIST CODE f ACTIVE UGi t EIEMPT UGT 1 CLOSED UST SWEEPS PRGN/SUB CODE DATE <br /> L <br /> S 1 COMP <br /> EH 23 044 (12/88) <br />