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Underground Stox-w;e Tank Program - Farm Tani. lformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or B (NESS NAME CONTACT NAME <br /> A <br /> C ADDR (Street addres�TAN ocation) PHONE# (with area code) <br /> I G <br /> L <br /> I CITY d�U� STAIN ZrP�20DE NEAREST CRO 5 STREET <br /> zt <br /> T 1,,II 4C 1 /luv) <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# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> IRI 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 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E —PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed o&q[Qsediepl r` <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) OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED <br /> Q�� , <br /> K <br /> F �O ^ <br /> O / e <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW LEDGE IS TRUE AND CORRECT. <br /> NAMTITT_E DA7`C <br /> OFb USF;ONLY <br /> SWEEP-.# COMP# LOC CODE DISTCODE#ACTIVE UGT I#EXEMPT UGT #CLO.SED UGT I SWEEPS PRGM)SUB CODE DATE <br /> EH 23 044(12/88) <br />