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r <br /> Underground Sto. a Tank Program - Farm Tan formation Form <br /> i FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONI"ACI'NAMIL' <br /> A �l P Flo _.v i <br /> C ADDRESS(Street address of TANlocatio PHONE# (with arca code) <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T c,TOC I�TON q P - ?15 205 <br /> YCHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> 0 NAME OPER,A,d'OR CW44!, r: <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (With area code <br /> Ai98 <br /> T CITY STATE ZIP CODE <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 /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I 'LIP CODE, <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (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 ESTIMA'tTD DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N _ <br /> 00 <br /> I JV C1 1 ' f G-2 <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COM' TED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAM TITLE '7 DATE <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODs: DIST CODL #ACTIVE UG'f #ExE'MPT UGT #CUJSED UG'I' SWEEPS PRGMfSUH CODE DATE <br /> 1H 2-1044(12!138) <br />