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Underground StoralpTank Program - Farm Tank 0-ormation Form <br /> FACILITY/SITE INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A 5 . mozkt-'li7Yfl 5. MMLM0TJ <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I - 1(a2 1-tt 4W ILO yW J$) 31�S'4{pct <br /> L <br /> I CITY I STATE I ZIP CODE I NEAREST CROSS STREET <br /> T L. I %Zoe GA `1'5336) MLl4KLa- 4 <br /> Y I 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 CONTACI'NAME <br /> P <br /> E MAIUNG or STREET ADDRESS OPERATOR PI IONE N (with area code) <br /> R <br /> A <br /> T CITY STATE I 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 S , ti-t O fat M 01-0 _ M stat tr OTO <br /> W <br /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E X141 O tT ct5Lj53T-i '14 3a" Szft.J <br /> R CITY I STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACIIVB 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 TANKSIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENILY EMPTY IF PERMANFNTLY CLOSED CLOSURIi IN PLACE <br /> K A. TO, tl l<.S 2C. t-t <br /> N <br /> F <br /> O <br /> TINS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO"IE BEST OF MY KNOWLEDGE,1S TRUE AND CORIUx-t'. <br /> NAME TITLE 6_ Ictti DATE g <br /> OFFICE USE ONLY <br /> SWBEPSY COMPtt IOC CODE Dal'CODE -ACIIVE UGI' #uxEMPT UG'I' aCLUSEDUG'I' SWU.'MPRGM/SUBCODL UA'fli <br /> • RN OI A"It)IRA% <br />