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Underground Stora•Tank Program - Farm Tank formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or,BUSINESS NAME CONTACT NAME <br /> A __Y,41;1 <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I <br /> L <br /> I Cify STATE I ZIP CODE NEAREST CROSS STREET <br /> T ;.Sclzzla-kl Cel e153 &,&e <br /> YI CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O 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 /> 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 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 CLOS URE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N � / <br /> K UO D Q /1?0 3.--lev—P 2S <br /> I a1vo S <br /> N <br /> F <br /> O <br /> THIS FORM I BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE (,�� DATE _ J <br /> OFFICE USE ONLY <br /> SWEEPS# I mMP# LOC CODL. DIS- CODE #ACTIVE UGI' I#EXEMPT UGI- #CLOSED UG'I' I SWEEPS PRGMISUB CODE DATE <br /> EH 23 044(12/58) <br />