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Underground Storage Tank Program - Farm Tankl4iformation Form <br /> FACILITY/SITE INFORMA'T'ION (Complete this form for each FARM TANK location.) <br /> F FARM or BINES NAME CONTACT NAME <br /> A V' 0 <br /> C ADDRESS(Street address of T K location) / PHONE# ( 'th code) <br /> L -�tl�.I <br /> I CITY STATE I ZIP CODE NEAREST CROSS S ET <br /> T M o` Ac: ) . �/J 7/�O <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 tt (with arca code) <br /> R <br /> A <br /> .1 CITY STATE ZIP CODE <br /> O <br /> R I I 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 Stiff t-ti L Z <br /> W MAILING or STREET ADDRESS // 0 HONE with area cod <br /> E AZ - $V� 'i <br /> R CITY STATEZIP CODE _ If <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,E, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or ) <br /> UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) <br /> T TANKSIZE 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 /> THIS FORM HA.S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME , 'TITLE �,vy�yy.w.O �.NJ.a...r�tl DATE <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODE DIST CODE N ACTIVE UGT #EXEMPT UGT 1#CLOSED UGT SWEEPS PRGM/SUB CODE DATE ' <br /> EH 23 044(12/88) <br />