Laserfiche WebLink
. Underground Storms Tank Program - Farm Tank 4formation Form <br /> FACILITY/SITE INFORMATION (Complete this form I'or each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACTNAME <br /> A <br /> C ADDRESS(Street address of TANK location) l p� PHONE# (with area code) <br /> IS�a'V �u — <br /> L <br /> I CIT ,� STA IP22CO�^D1E NEAREST CR,,OSIlS S EET <br /> T 91> <br /> Y CHECK H RE 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 ZIP CODE <br /> O <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 OWNER CONTACT NAME <br /> O <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX M O b(�W b I/� <br /> ,l, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capaciii) <br /> Y EXEMPT FARM TANK SITE ( g Y) <br /> P A[1.under round"TANKS a!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 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 /> K 3� 8 <br /> I <br /> N <br /> F <br /> O <br /> THIS rKM H COMP ND PENALTY-OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AN U CORRECT. <br /> NA 'D'TL DAIT'. <br /> OFFI E S .ONLY <br /> SWEEPS# COMP# LOC CODE DIST CODEj#ACTIVE DOT #EXEMPT UGT #CLOSED UGT I SWEEPS PRGMISUB CODE DATE <br /> Ell 23 044(12/88) <br />