Laserfiche WebLink
Underground Sto0e Tank Program - Farin Tan Information Form <br /> ACILTTY/SITE INFORMATION (Complete this form for each FARM'TANK loc n.) <br /> F FARM or BUSINESS NAME CONTACI'NAME <br /> C ADDRESS(Street address of TANK location) PIIONE N (with arca c <br /> L <br /> I CITY �.._ ATE ZIP CODE NEAIt,Es,r CROSS S'I11ECi' <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete If hirormation different from above.) <br /> O NAME OPERA'I'Olt CONTACI'NAMI: <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PI IONE 0 (will)arca cock) <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 CONTAUf NAMI? <br /> O <br /> NMAILING or STREF,TADDRESS OWNER PHONE N(with arca code) <br /> E — -- <br /> R CITY STATE ZIP CODE <br /> CHECK 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 (Idst additional tank Information on separate sheet If needed.) <br /> T TANK SIZE OiEMICALS STORED EST'IMA'IZ;D DATE I-AS1'USED ML'I1IOD OF CLOSURE DA]'L'OI'Itl:MOVA1.OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENILY EMI'L'Y IF PERMANFIJILY CLOSED CLOSURE IN 14-A(T. <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> TI FORMHAS ll O U DE PENALTY OF PEIUURY,AND T'O TIII?UGS'r OF MY KNOWLEDGF, IS TRUE AND CORI(ECI'. <br /> N ITI'LE �1W DA'IT: <br /> OFFICE USE ONLY <br /> SWEEPS M COMP 0 IAC;CODE I DtS'r CODE 0 ACIIVL;'UG-1- 0 EXEMPT UCH' M CI )SED UG1' SWEEPS PRGMISUD CODE DA'I I? <br />