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Underground StoragTTank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONLACr NAME f <br /> C ADDRESS(Street address of TANK location) PHONB N (wish area code) <br /> I 1V/01 1F,>2 <br /> I CITY SATE ZIP CODE I NEAItES'r CROSS STREET /•� <br /> Y CHECK HERB if this ADDRESS should be used for Legal Notification <br /> OPERATOR!NFORIe44TION &ADDRESS (Complete If information different from above.) <br /> 0 NAME OPERA'I'OR CONT'ACl'NAME <br /> P <br /> E MAILING or STREET ADDRESSn/ OPERATOR PI IONE i(Kith arca code) <br /> A <br /> T CITY STA'T'E 'LIP CODE <br /> O <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 CONTACrNAME <br /> orner J r <br /> art /ori <br /> NMAILING or STREET ADDRESS OWNER PHONE k(with area code) <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 /> ,1, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P f EXEMPT FARM TANK SITE /0 6cA�, (ALL underground'fANKS 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 CEEMICALSSTORP.DFST'IMAn-D DATE LAST USED MEILOD OF CLOSURE DA'Z'E 01;REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSUR]i IN I'L10E <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> TIUS FORM PAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,ISTRUE AND CORREUr. <br /> NAME % / ft'fLE DATE- }' ,, VE <br /> OFFICE USE ONLY <br /> SWEFPSM COMPO LOC CODE DISTCODEM AC11VL UGT 1 0EXEMPT UOT #CLOSED UG-ISWIJ:I-S PRGM/SUb CODE DA'lli <br /> EH 23 044(12/88) <br />