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1N E Rhee *-Ob UN®'E G �. � � - -�kNkS <br /> Underground Storage Tank Program - arm Tank�cfiformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> C ADDRESS(Sheet address of TANK location) PHONE# (with area code) <br /> I <br /> L <br /> I CITY STATE I ZIP C059 NEAREST CROSS STREET <br /> T <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 /> TCITY STATE I 21P CODE <br /> O <br /> RCHECK 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 /> Jim <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E R Q Y,, 6 <br /> R CITY I STATE ZIP CODE <br /> C ',Z30 <br /> CHECKHtRE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS atite removed or losed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if n <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 /> O <br /> 1 1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW LEDGE,IS TRUE AND CORRECT. <br /> NAME _ Q TITLE DATE <br /> OFFICE USE ONLY <br /> SWEEPS N COMP N I TAC CODE DIST CODE N ACTIVE UGT N EXEMPT HOT N CLOSED HOT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12!88) <br />