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Underground Sl" 'tge Tank Program - Farm Ta Inrormation Form <br /> -- <br /> I+ACI I,1'1'Y/SI'Z'E 1NIFORMA'I'ION (Complete this form for each FARM TANK location.) <br /> F FARM orDUSINISSnNAME ��7ACTNAMJy <br /> A <br /> C ADDRESS(Street address of TANK location) fiA (withareacode) <br /> 1 233 i .3L q ) - ,591- :,637 <br /> 1 CITY STATE "LIP CODE NEAREST CROSS STREET <br /> T �1 ,� (n rJ3 3G 4• <br /> Y CIIECK HERE if this ADDRESS should In used for Legal Notificatinn <br /> OPERATOR INFORMATION &ADDRESS (Complete If information dilTerent from above.) <br /> 0 NAME' OPERATORCONTACTNAME <br /> p <br /> E MAILING orSTREETADDRCSS <br /> R OPERATOR PHONE p (with arca code) <br /> A <br /> T CIfY ST'rt"TE 7,IPCODE <br /> O <br /> R CIIECK IIERIi is this ADDRESS should he used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME <br /> 0 OWNER CONTACT'NAME <br /> NMAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> E <br /> R CITY SfA'CI: !II'CODE <br /> CHECK HERE if this ADDRISS should be used for Legal Notification <br /> CIIECK APPROPRIATE JJOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > J,100 gallon capacity) <br /> Y <br /> p EXEMPT"FARM TANK SITE (ALL undcrgmund TANKS at site to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK S!TE (AIL underground TANKS at site removed or closed in place) <br /> UNDE'RCROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DA'Di I-15'r ItSED METI IOD OF CLOSURE: DATfi OP REMOVAL OR <br /> A (GALLONS) CURREN I'LY OIt PREVIOUSLY IFCURREN'TI.YEMPT'Y IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 1/rqoo ca5oil I'C / tvrto2 -.ZD—$] <br /> I /D DCp Dlese� ? <br /> -9-7 <br /> N 500 Gasollnf- to <br /> F <br /> v v 64se1 I/ <br /> TIIIS FORM IIAS BE RN COMI LTD UNUfiR PIiNAta'Y OP I'ERJIIRY,AND TO TIII{IIIS'F Oh MY KNOWLEDGE rS TRIIR AND CORItF.CT. <br /> NAMH, DATTi <br /> OFFICE, USE ONLY <br /> SWIT11SM COMPa LOCCODP: DIST C0DIiaA(7I1VIi I1GT NIXEMPT U(II' HCIOSEDUCIT SWEEPS PRGM/SUB CODP. UATI: <br /> Elf 23 04,4n(1122/88) p <br />