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Underground Ae Tank Program - farm T .` <br /> g formats <br /> FACILITY/SITZ;INFORMATION (Complete this form for each FARM TANK locatiMA 4 19011 <br /> F FARM or D USINESS NAME on.)n <br /> A / CONTA NAMI ERMI /S,7,R Ec <br /> C ADDRESS(Street address OITANK location) <br /> I PHONE N (with <br /> L � S� � ld'12c� —�c> area cpde) <br /> I CITY R0,7 -/ � �J� `Z <br /> T ST ZIP CODP NEARESTT CCRIOSS SIREEI' <br /> Y C PC 1K IPRE if this ADDRESS sh uld be used for Legal Notification <br /> O NAME F ,vim <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> P L OPERATOR CONTACT NAME <br /> E MAIIIN�i or STREErTAD G <br /> tEss <br /> A f OPERATOR PHONE N (with area code) <br /> OTY <br /> Cly STATE ZIP CODE <br /> R C r� <br /> IPCK HERE is this ADDR t J G,4 <br /> TSS should be usW for Le al Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME <br /> 0 �. <br /> OWNEItCONTACTN / <br /> w � )2VYL_� �, E <br /> fi MAILING�r STItADDRPSS cx <br /> l( OWNER PHON N(with area code) <br /> , s U p u <br /> R CITY I <br /> STATE ZIP CODE <br /> CHEC IiPRP.if this ADDRESS should he used for Legal Notification <br /> CHECK APPROPRIATE PDX <br /> T ACI'IVP FARM TANK SITE <br /> Y (One or more underground TANKS > 1,100 gallon capacity) <br /> PERMANENTLY CLOSED FARM TANK SITE <br /> P EXEMPT FARM TANK SITE <br /> E (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> (ALL underground TANKS at site removed Or closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank I formation on separate sheet If needed.) <br /> T TANK SI'L11 <br /> A (GALLONS) CURRI�3MLyCp pSRPrORLID LY ESTIMATED DATE'LAST USED <br /> N Il CUIULENTLY EMPTY METI"IOD Of LY CL.AUI DATE OF REMOVAL_OI( <br /> IF YERMANf•.N'fLY CL0.SED CLOSURE IN PLACE <br /> 0 <br /> J <br /> 77IfS FORM'LAS DEEM COMPLI?'I'ED UNDER PENALTY OP YEIUURY,AND TO 77115 BEST OF MY KNO WLLSDCE,1S TRUE AND COItWSCT. <br /> NAME <br /> OFI+ICI'-USE ONLY <br /> DATE <br /> SWEPS# WMPN LOCCODL' D1S'l'CODENACI7VL'UGT N � • � <br /> EKEM17 UG'1' NCL.q,SIiD UGT SWEEPS I'1(GM/SUU WUE <br /> UA7'I: <br /> PI I ?1 044(1?/NH) <br />