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Undirground Stogwank Program - Farm Tan"rmation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or DUS11 jESS NAME j CONTACTNAME <br /> A /` 1 7 or�=i t� . <br /> C ADDRESS(Street address of TANK location) /_`5�'/9�U�, PHONE M (with area code) <br /> I CITY / STZIP CODE NEAREST CROSS TRIiET <br /> T5��� <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 A/ <br /> E MAILING or STREET ADDRESS OPERATOREN (withareacodc) <br /> R J� <br /> [ CITY STATE L —] <br /> IP CODE <br /> o <br /> R1 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 N(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CIIECK HERE if this 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 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 SIZF. CHEMICALS STORED ESTIMATED DATE LAST USED METI IOD OF CLOSURE DATE OF REMOVAL.Olt <br /> A (GALLONS) CI mA5N7LY OP.PREVIOUSLY IF CURRcraLY EMPTY IF PELtMANENTLY CLOSED CIOSUIU/IN PLACE <br /> N <br /> K v7 ! y <br /> G1" r <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TIIE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME 6 ,7 I TITLE i / DATE <br /> OFFICE USE ONLY <br /> SWEI•.PSN COMP IOC CODL' DISI'CODEN ACIIVE IIGT 1 0EXEMPTUOT 0CLOSED UGI' SWEET'S PRGM/SUU CODE DA'L'li <br /> EH 23 044(12/88) <br />