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Underground age Tank Program - Farm <br /> Information Form <br /> I+AGI,ITY/SI'T'E INFORMATION (Complete this form for each FARM TANK location.) 2"6 <br /> F FAR MoLDUSINIS N ME <br /> A / J 111, CON AKIN V <br /> C- ADDRESS(Street address o TANK location <br /> I /]tf /—c PHONFq (with arca code) <br /> I CITY G Iv 2�R- 38 Q'D <br /> ��� STATE ly <br /> ZIPCODE NM- I EST CROSS STREET <br /> T G9 q�320 <br /> Y <br /> CIII:CK IIFRE if Ihis ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> FA <br /> OPERATOR CONTACT NAME <br /> NGorSTREETADDRESS <br /> OPERATOR PHONE N (with arca code) <br /> STATE Z.IP CODE m R <br /> R <br /> CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INh'ORMATION&ADDRESS (Complete if different from above. <br /> PERMIT/SERNlCES <br /> Kcvly <br /> OWNER CONTACT NAME <br /> r5T11EGTAUDRFSS <br /> OWNER PHONE k(with area code) <br /> CK IIERE if Ihis ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EAUMPT FARM TANK SITE (ALI,underground TANKS at site = to or < 1,100 gallon capacity) <br /> E PI?RMANI::N1'LY CLOSED FARM TANK SITE <br /> (ALL underground TANKS at si m <br /> eoved closed in place) <br /> 01NDERGROUND TANK INFORMATION (List additional tank information on separate sheet irneeded.) <br /> T 'TANK 517,11 CilEMICAISSTOR1iD ESTIMATED DATE V�S'P J <br /> A (GALLONS) CI1RIiIiN'I'LY OR PREVIOUSLY IF CIIRIiIiNfLY f:MV'1'Y ILSIiIMIiTIIOD OF CLOSURE DATP.OF IIEMOVAL OR <br /> N IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K <br /> 1 <br /> N <br /> r <br /> O <br /> THIS FORM HAS BEEN COMPLI,ITT)UNDER PENALTY OF PER.IIIRY,AND'I'O Till IIIS'F OF MY KNOWLEDGE,IS TRITE AND CORRECT. <br /> NAMP: �'� � a-.�_ �� � 'T'I'TLE � � ,✓ <br /> OFFICE USE ONLY DATE <br /> SWI{Iil'Sx COMP# LIX'CODI; DIST CODE NAC:"I'IVli 11Gl' xBK F.MP'1 UGI 0CLOSED 1101' SWEEPS PROM/SUD CODE <br /> DATE <br /> Ell 23 044(12/88) <br />