Laserfiche WebLink
anN WQUIN L.UCAL HEALTH DISOICT <br /> UNDERGROUND STORAGE TANK PRO6RAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete thio Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A Z5,( evs 81V c . El <br /> l fir} <br /> C ADDRESS (StreetAddress of TANK location) PHONE 1 'TW AKA COOK <br /> I <br /> � . Mil f�cf �o 9 I-ce <br /> T CITY STATE IIP CODE NEAREST CROSS STREET <br /> Y ��eu q5 -1-316 u.✓c.�nJ <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> ° S fie_ <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE IIP CODE <br /> R <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION It ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA CODE <br /> CITY STATE IIP <br /> IR <br /> CODECHECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Bax <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 R to or ( 1,100 gal. capacity) <br /> E <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site emove r 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 0 REMOV OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSUR ACE <br /> N <br /> K 'e, 31J' Ff <br /> 1 <br /> N <br /> F <br /> 0 <br /> THIS FO S BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, is TRUE AND CORRECT <br /> NAME TITLE DATE <br /> OFFICE S E ONLY <br /> SWEEPS 1 COMP t LOC CODE DIST CODE 1 ACTIVE UGT a EXEMPT UGT 1CLOSED UGT SNEEPS PRfiM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />