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Underground Stotge Tank Program - Farm Tankformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME C CONTACT NAME l <br /> C ADDRESS( et address of T K ocation) PHO # (with are code) <br /> L <br /> I CITY STATE ZIP CODE I NEAREST CROSS STREET <br /> �5�kc5— Frcn_ <br /> Y 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 CONTJ?P� <br /> P ^^ <br /> E MAILING or STREET ADDRESS OPERATOR PH1 (wit <br /> R ((�I <br /> .1 CITY STATE ZIP CODE PLS 11 <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. 9� <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <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 /> ,l, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y - B B P <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 CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K /ece <br /> ae-4L <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW LEDGE,IS TRUE AND CORRECT. <br /> NAMETITIN DATE <br /> OFFICE USE O Y <br /> SWEET'S# COMP# IAC CODE DISC CODE#ACTIVE UGT #EJCEMPTUGT #CLOSED UGT I SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/58) <br />