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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME n CONTACT NAME <br /> A c . (,E v � C � <br /> C ADDRESS(Strut address of TANK location) PHONE N (with arca code) <br /> I CITY STATE ZIP CODE I NEAREST CROSS STREET <br /> T �SC cr.�� v� � � <'�� <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 OPERAI'OR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 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 OWN ERCONTACENAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> E <br /> R CITY STATE 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 /> (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P EXEMPT FARM TANK SITE <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 TMT::SaB CHEMICALS STORM ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSUIU;IN PLACE <br /> K 4� ^v'ec 5vr k <br /> I � 'l0 <br /> p J t lit <br /> F ffi (7c 4 <br /> Lo <br /> — <br /> ,nus FORM HAS B COMPLETED UNDER PEN TY OF PERJURY,AND T'O THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> i <br /> ITTLE DATE - T�f <br /> OFFICE USE ONLY <br /> SWEEPSN CUMPM WCCODBLISTCODBNACITVE 71 017UiMPT'UG'I' NCLUSEU UG'1' SWLilil5 FI1GA1lSUDCOUE UA'I'h <br />