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Underground Store Tank Program - Farm Tanlrformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> I I1T5 i +nl tnc L otr t� / 7 <br /> L <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> Z' CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P ��� ti \ rG C�v • v <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> T CITY < T TE ZIP CODE <br /> oOtk Cf� Cl5r' ,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 /> 0 61 Me PNS vA eA) r. <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> LET ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <br /> 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 /> K <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 TRUE AND CORRECT. <br /> NAME7=7 % TITLE DATE <br /> �, y <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODE DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />