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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 /> F FAff or BUSINESS C rAr Nr s <br /> C ADDRESS(Street address of TANK oration) PHONE M (with area code) <br /> I /YVA <br /> I CITY I STATE ZIP CODE NEAREST CROSS S17tGEf <br /> TrJ L C�t 1 Gc{WI <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 l OPERATORCONTACT NAME <br /> P <br /> R TR <br /> MAILING or STREET ADDRESS OPERATOR PI10NEW jit%i'ta°area o'dej <br /> A <br /> T CITY STATE ZIP CODE ¢ <br /> o � > X199 <br /> RCHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) J ''tr p!ilT t <br /> NAME �. OWNER CON1'ACTNAME' <br /> W �= T-� L <br /> N MAILING or STREET ADDRESS OWNER PHONE H(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 /> .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 TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank Information on separate sheet if needed.) <br /> T TANK SIZE CHP.MICALS STORED ESTI tA:TD D.:TEIAST USED MOMODOFCLCSURE DA'M OF REMOVAL Olt <br /> A (OALLoNS) CURRENTLY OR PREVIOUSLY IF CURREMILY EMPTY IF PERMANENTLY CLQSED CLOSUIO:IN PLACE <br /> N <br /> K C^! pp <br /> F <br /> O <br /> ntis FO L UNDER P F PERJURY,AND TO TIIE BEST OF MY KNOWLEDGE,IS TRUE AND CORIU?Cf. <br /> NAME TITLE DATE- <br /> OFFICE <br /> ATEOFFICE USE ONLY <br /> SWEEPS" COMP" LOC:CODE DIS'r C.ODEaACIIVLW'1' ouumPI'UG'1' YCLOSEU UGI' I SWBBPSPROK/SUBCOUB UA'I'li <br /> EH 23 044(12/80) <br />