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L IJHUUAN L—UGAL HEALTHll�FRICT <br /> LANDEUND STORAGE TANK PROGRAM - FARM TANK INFORMATLpN FORM <br /> R O <br /> FACILITY/SITE INFORMATION (Complete thle Form for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F <br /> A _ r fav lT Z,(I�-, <br /> C ADDRESS (Str et address of TANK location) PHONE K! ARCA CODE <br /> I <br /> T CITY_ STATErfliP CODE NEAREST CROSS STREET <br /> Sz3G <br /> v HECK HERE if this ADDRESS should he used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE t WITH ARCA coo¢ <br /> R <br /> A <br /> T <br /> O CITY STATE LIP CODE <br /> CHECK HFRE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION t ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA CODE <br /> W <br /> N <br /> E <br /> R CITY STATE LIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> Cheet Appropriate Box <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <br /> X PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site emoved 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 /> N (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSUR �CACE <br /> K �CCtiI QiC ti Pc� 3 -13 <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE DATE <br /> �-sa'y7r:2 f <br /> OF CE USE OHL <br /> SWEEPS tCOMP t LOC CODE DIST CODE t ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />