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Underground St*ge Tank Program - Farm TaWformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARIWor BUSINESS NAME r. CONTAFA NAME <br /> A Uuusev C <br /> C ADDRESS(Street address of T K location) PHONB# (with rea code) <br /> L <br /> CITY I STATE ZIP CODE'} NEAREST CROSS STREET <br /> T L,04 I <br /> Y I 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 CONTACT NAME <br /> P <br /> RNG or STREET DRESS l ( OPERATOR PH NE# (with area code) <br /> A --M A) � s ff�/c`/1 6 —�Z <br /> T CITY STATE I ZZIIIP CODE c'l <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 <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE I 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 /> P EXEMPT FARM TANK SITE ( ground underg round TANKS at site = to or < 1,100 gallon capacity) <br /> /� <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or dosed 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 CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY <br /> {OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K <br /> 1 LAW ALA-, <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UN ER PENALTY OF PERJURY,AND TO THE BES OF MY KNOWLFDGE,IS TRUE AND CORRECT. <br /> NAME TITLE C DATE <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODE DIST CODE#ACTIVE.UGT #EXEMPTUGT #CLOSFDUGT SWEFPSPRGM/SUBCODE I DATE <br /> Ell 23 044(12/88) <br />