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Underground St*e Tank Program - Farm TaiOnformation Forfn hACI I,I'I'Y/SI'Z'E INFORMATION (Complete this form for each FARM TANK location.) 1. FARM or BUSINESS NAME CONT N A C= ADDRESS(Street address of T NK la n) PHONE N (with area tale) L 1 C11 STATE I ZIPCODE NEAREST CROSS STREET a T Y CHECK HERE if this ADDRESS should be used for f egal Notification OPERATOR INFORMATION &ADDRESS (Complete if Information different from above.) 0 NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE 0 (with area code) R A T CITY STATE I ZIP CODE 0 R CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) NAME OWNER CONTACT NAME 0 W MAILING or STREET ADDRESS OWNER PHONE N(with area code) N E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for legal Notification CHECK APPROPRIATE BOX T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y ALI,under round TANKS al site = to or < 1,110 gallon capacity) P EXEMI''1'FAIiM'I'ANKS171i ( g 6 P Y) E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List additional tank Information on separate sheet if needed.) T TANKSIZE CHEMICALS STONED IS1'IMA'I71D DAIT I AST USED METIIODOFCLOSU`RE DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IFCURRENI1.Y EMP'T'Y IF PERMANENTLY CLOSED CLOSURE,IN PLACE N K C✓L " F O T][IS FORM HAS BEEN COMPLETED UNDER PLNAI:IY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAME 'I'ITI,1' DATE r OFFICE USE ONLY SWEF:PSN C:OMI'N 11JC COOL• DISTCOUE N ACTIVE IR;T I#EXEMPT UUJ' #VLOSED UGT SWEEPS PRGM/SIIB CODE DATE El 123 044(12/88)