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- Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/BITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A U ' <br /> C ADDRESS(Street address of TANK location) PHONE N (with area code) <br /> I � l <br /> Ll <br /> I CITY STATE ZIPCODE NEAREST CRO STREET <br /> T SAO ' C -11 — <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> p <br /> E MAILING or STREET ADDRESS r OPERATOR PHONE N (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> RI 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 /> 0 <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 /> ACTIVE FARM TANK SITE <br /> T V (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 SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CIASURP. DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME - TITLE E'--" DATE -?3-J <br /> OFFICE USE ONLY <br /> S WEEPS M I COMP N I LOC CODE DIST CODE N ACTIVE UGT I M EXEMPT UGT M CLOSED UGT I S WEEPS PRGKSUB CODE DATE <br />