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Underground Sto*.; Tank Program - Farm TankWormation Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F-FARM or BUSINESS NAME CONTACT NAMP A C AA&L-& S e w I C-*ILL E[,� 1S C ADDRESS(Street address of TANK location) PHONE# (with area code) I L I CITY STATE ZIP CODE I NEAREST CROSS STREET T Lt:5DI CA 9S1y0 gdLUCzL Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) 0 NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A T CITY STATE I ZIP CODE O IRI I CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) NAME OWNER CONTACT NAME O NMAILING or STREET ADDRESS OWNER PHONE#(with area code) E R CITY STATE 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 ALL under round TANKS at site = to or < 1,100 gallon capacity) P -EXEMPT FARM TANK SITE ( g g 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 TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K SSO I N F O THIS FORM HAS BEEN COMPLL rED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. NAMECN, /-\ —,,Z' ITITTLE DATE OFFICE USE ONLY SWEEPS# COMP# I LOC CODE DIST CODE#ACTIVE UGT #EXEMPTUGT #CLOSF,D DOT I SWEEPS PRGM/SUBCODG DATE EH 23 044(12/88)