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i Underground St^e Tank Program - Farm TaAlInformation Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME A 7 C ADDRESS(Street address of TANK location) PHONE# (with area code) L � �� L, Cc�� >✓�c )Z�15 I CITY STATE I ZIP CODE NEAREST CROSS STREET T - o ;�,7 o Y I 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 //'( G/— / E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A T CITY STATE I ZIP CODE O R 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 J%7�PL NMAILING or STREET ADDRESS OWNER PHONE#(with area code) E R CITY STATE I ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX .I. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y EXEMPT FARM TANK SITE ( g B capacity) P ALL underground TANKS a[site = to or < 1,100 gallon ca acit 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 K I N F O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. NAME /j- TITLE DATE OFFICE USE ONLY SWEEPSN COMPN IACCODF: DISTCODE #ACfIVEUGT I #EXEMPTUGT #CLOSEDUG'f SWEEPS PRGM/SUB CODE DATE f 'v EH 23 044(12J8S)