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Underground Storage Ok Program - Farm Tank Infd►ation Form$4,f-,L&Z <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) ' zll 07 <br /> F FARM or B SINESS NAME CONTAC AME <br /> A �� 2 <br /> CADDRESS(Street address of TANK location) PHONE# (withareacode) / <br /> L / — /c �l <br /> I CITY STATE ZIP CODE NEAREST C OSS STREET <br /> T C— <br /> Y I CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 N OPERA OR CONTACT NAME <br /> P 'erQ <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with arca code) <br /> R .CI e /� — <br /> A <br /> .I. ITY STATE I ZIP CODE <br /> 0 <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 OWNFA CONTACT NAME !I <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE.#(with arca 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 /> ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g 8 capacity) <br /> P ALL under round TANKS at site = to or < 1,100 gallon ca acit <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 TANKSIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATEOFREMOVALOR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K �" G <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. <br /> NAME TITLE DATE <br /> OFFICE USE ON 61 <br /> SWEEPS# COMP# I LOC CODE DIST CODE#ACTIVE UGT I#F.XEMPTUGT #CLOSEDUGT SWEEPS PRGMiSUB CODE DATE <br /> 1 <br /> EH 23 044(12/88) <br />