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Underground Storage Tank Program - Farm TankInformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> i <br /> A <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> L <br /> C STATE ZIP CODE NEAREST CROSS STREET <br /> I <br /> A <br /> T .SAO c <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification C <br /> G `F T <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different fronfir ve.) (j 4 <br /> 111 <br /> NAME OPERA TA AI91E <br /> O <br /> /T tiT <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHO. 4 ,Frrea code) <br /> R / <br /> TCITY STATE I ZIP 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 OWNER CONTACT NAME <br /> O <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE I 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 EXEMPT FARM TANK SITE ( g gallon capacity) <br /> P AL[.underground TANKS at site = to or < 1,100 Ilon ca cit <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at remov or closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMP'T'Y IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> 1 1 <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 <br /> OFFICE USE ONLY <br /> SWEEPSN WMP# LDC CODE I DIST CODE#ACTIVE UGT I #EXEMPTUGT #CL03EDUGT I SWEEPSPRGM/SUBCODE DATE <br /> EH 23 044(11/88) <br />