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Underground St Ige Tank Program - Farm Tan::information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A !F-"lc 1C,ff 1J6 <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I kilt <br /> I CITY STATE pZIP CODE I NEAREST CROSS STREET <br /> T ��G1��LN lS.L6S CU.-✓ fE/l <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> 0 <br /> R CHECK HERE is this ADDRESS should he used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> O <br /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <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 /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P EXEMPT FARM TANK SITE <br /> F' PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at sit removed r closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank Information on separate sheet If needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE[AST 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 /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME J TITLE DW,;,; Wit. DATE7-S- f <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# IOC CODE DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGmrwB CODE. DATE <br /> EH 23 044(12/88) <br />