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Underground Store Tank Program - Farm Tank formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME // CON ACT NAME <br /> A L)P— 3o Fl f Sam <br /> p2-6 N (with e� Se) Z <br /> C ADDRESS(Street address of TANK location) e <br /> I ( D FST - O <br /> ICITYSTATE ZIP CODE NEAREST CROSS STREET <br /> T f vol-ia- 0,, 4 :at- <br /> CHECK HERE if this ADDRESS should be used for Legal Notification ;Y <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.)-------------- <br /> W <br /> OPERATOR CONTACT SAME <br /> s �, <br /> RESS OF <br /> PHONE X (with area code) <br /> , � 7/ J� 7- 835-2626 <br /> STATE ZIP CODE <br /> � 536his ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME WN <br /> OE CONTACCNAME <br /> p A) Ili g� )1 O 5 <br /> W MAILD9 or STREET ADDRESS / 7 OWNER PHONE H(with area code) <br /> N <br /> E ._ <br /> RCITY TE ZIP CODE <br /> 13 q_S�d <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> TNY& 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 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 /> I <br /> N <br /> F <br /> 0 <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 e) <br /> OFFICE USE ONLY <br /> SWEEPSN GOMPN LOC CODE DIST CODE N ACTIVE UGT I NEXEMPTUGT NCLOSEDUGT I SWEEPS PROM/SUB CODE DATB <br /> EH 23 044(12/88) <br />