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Underground Stoles a Tank Program - Farm Tankylformation Form <br /> hACILITYISITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM BUSINESS NAME CONTACT NAME <br /> A ice/ —O <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I <br /> L <br /> AW 4zz�- <br /> I CITYSTATE ZIP CODE NEAREST CROSS STREET <br /> T <br /> Y CHECK HERE if thiLT=Ess <br /> should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS mplete if information different from above.) <br /> 0 NAME VOPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET )SSS OPERATOR PHONE# (with area code) <br /> R J <br /> A <br /> T CITY STATE ZIP <br /> O <br /> R CHECK HERE is this ADDRESS sho m for Legal Notification. <br /> PROPER'1 Y OWNER INFORMATION &AMR omplete if different ro it a ve.) <br /> NAME ER NTA CT NAME <br /> 0 (" <br /> N MAILING or STREET ADDRESS OWNER PHONE (with am code) <br /> E <br /> R CITYTE ZIP CODE <br /> this FS should be used for Legal Notification In <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE or ore underground TANKS > 1,100 galf6h capacity) <br /> Y EXEMPT FARM TANK SITE derground TANKS at site = to or < 1,100 Tgjjacapacity) <br /> P <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underg T at site removed or closed in pla ) <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separat eet 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 EMPTY IF PERMANENTLY CLOSED CLOSURE IN PIACE <br /> N <br /> K <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. <br /> OFFICE.USE ONLY <br /> SWEEPS# I ODMP# I LOC CODE DIST CODE #ACTIVE UGT #EXEMPT UGT #CLOSED GOT SWEEPS PRGmrwB CODE DATE <br /> EH 23 044(17/88) <br />