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Underground Stort Tank Program - Farm Tank 11 ormation Form <br /> FACILITY/SITZ✓INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONT, `:I'NAME <br /> A <br /> C ADDRESS(Street addmss ofTANk location) f PHIOjNEr # (YS thN ilea cod i,; J <br /> L <br /> I CITY ATE ZIP CODE NEAREST CROSS S'lItEEP <br /> T c[Y7?7 CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR 1NFORAIATION &ADDRESS (Complete if Information different from above.) <br /> 0 NAME 01'ERATOlt CON NAM Li <br /> P <br /> R IvUI-11.1110 or STREET ADDRESS OPERATOR P Il t� <br /> negal <br /> icc , <br /> r <br /> A <br /> T CITY STATE ZIP CODEENS J <br /> o pF2 NM <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) S <br /> NAME OWN ER CONTACT NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE#(With area code) <br /> E <br /> R CITY SPATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <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 sepurate sheet if needed.) <br /> T TANK SIZ13 CHEMICALS STORED ESTIMATED DATE LAST USED MGfNOD OF CLOSURE DATE OF REMOVAL On <br /> A (OALIANS) CURRENTLY OR PREVIOUSLY IPCURRIWILY EMPTY IF PERMANENTLY CLOSED CLOSUIUi IN PIA,,ccCCE <br /> K- Ahaw oaz V� ' � <br /> C7 V <br /> N <br /> F <br /> O <br /> TIUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOTHE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. <br /> NAMEy TITLE V\'C I DA'Ir- <br /> OFFICE USE ONLY <br /> SWEEPSY I COMPO LOC CODE DIST CODs*77-17 UGT Nl9t[iA4YT'UG'1' NCLOSED UGI SWEEI'51'RGMINUUCODE DATL <br /> Eli 23 044(12/88) <br />