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Underground St%,,z Tank Program - Farm Tan} ormation Form <br /> FACILITY/SITE,INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME J d6. CONTACT NAME i4111N] <br /> A <br /> C ADDRESS(Street ad rens of,rANrC location) / PHONE# (with area code) <br /> I <br /> L 7 y 1 wc''h '�— �G 2 5 1989 <br /> 1 CITY S/A�TE 'LIP CODE NEAREST CROSS STREET <br /> T �L,v '+rhe C=4 313 3(� MENTAL HEAL <br /> Y CHECK HERE if this ADDRESS should he used for Legal Notification PE <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 SPATE I ZI ODE <br /> O <br /> IRI I CIIECK 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 /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CIIECK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> .I. ACnVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g B capacity) <br /> P ALL underground TANKS at site = to or < 1,100 gallon ca cit <br /> E (i 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 sbeet if needed.) <br /> T TANK SI'2E 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 .�iii, /. ti �✓ rGe..te�Ol <br /> I etv�e.n! <br /> N Q <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO"IE BUST OF MY KNOWLEDGE,IS TI.UE AND CORRECT. <br /> X1 NAME c4t ez DATE <br /> OFFICE E ONLY <br /> SWEP.PSN (X)MP# IOC CODE I DISI'CODEN ACI'IVIi UGI' #EXEMPT UGT 0CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> P <br /> 1:112-3(144(12/118) <br />