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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME: co%rNt IF <br /> A Y cif">`n d' \ CZ. Its rlc KO✓ic <br /> C ADDRESS(Street address of TANK I°�I' n) PHONE# ( Eh area code) <br /> T CI ' �Of/t N / dE Sj 21 ZIPCODE N11LICS /j//C�tEEf' <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from ubove.) <br /> 0 N OPERATOR CONTACI'NAME <br /> - <br /> EI MAILING or STREETADDRESS OPERAI'OR PIIONE# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> 0 <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME / OWN ER CON'1'ACI'NAME <br /> 0 <br /> NMAILING or STR ADDRESS OWNER PHONE#(with area code) <br /> R CITY J STA"fE ZIP CODE <br /> n c(� �sz36 <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> ,L. ACnVB FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P P`LEMPT FARM TANK SII"ITE (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 IASL'USED MGI110D OF CLOSURE DATE OI'REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IP CURI(ENI'LY EMPTY IF PERMANEWI.Y CLOSED CLOSURE IN PLACE <br /> N <br /> K ,SOG 6 iw �_ / PIYk (/Cc y-( <br /> I r7cLCL IFSC � � t / /"PI19(3(/Pt" c 8y <br /> N <br /> F <br /> O <br /> TILLS FORM tVS REY44 COMPLETEUU E EN T1'OF PERJURY,AND TO TILE aFS'f OF MY KNOWLEUGG IS TRUEAND COR7(I{C'1'. <br /> NAME '��-. TITLE (,/ti/FY' DATEd'—�'—�`� <br /> OFFICE USE ONIY <br /> SWEEPSN I COMPO fIOCODE DLS'1'CODENACI1VLUG'1' #liX[iMY1'UG'f NCLU.SIiD UG'I I SWELL'I'ROM/SUU COUI, UA'I li <br /> EH 23 044(11/118) <br />