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Underground Stora Program - Farm Tank'1 ormation Form <br /> FACILITYJSITE INFORMATION (Complete this force for each FArd I TANK location.) <br /> i <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A G/z'�G� ,tT i�'i' CJV /✓'r r� �cs <br /> C ADDRESS(Street address of TANK location) PHONE 0 (with arca code) <br /> L <br /> I CITY STATE YIP CODE NEMLEST CROSS STREET <br /> T .,� 64— 1�2Y2 7 <br /> Y '-7CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE#i (with area code) <br /> R ... <br /> A <br /> T CITY STATE ZIP 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 CONT•ACr NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE a(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal NotiGeat' n <br /> CHECK APPROPRIATE BOX <br /> .I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P E)MMPTFARM TANK SITE (All.underground TANKS at site = to or < 1,100 gallon capacity) <br /> B PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at sitemovedr closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separate shect If needed.) <br /> T TANK SIZE CHEMICALS STORED EMMATED DATE LAST USE METHQD OF CLOS URE 1 AT U OF ISMO V It <br /> A (OALLONS) C JRRENILY OR PRSVIOL)SLYIFCURRENILY EMPTY IF PERMANENTLY CLCSP CLJSUR)s IN}'LACE <br /> N <br /> K Gs n1 <br /> N <br /> F <br /> O <br /> THtS FORM HAS B CO UNDER PENALTY OF PERJURY,AND TO 7111H BEST OF MY KNOWLEDGE,IS TRUE AND CORIUXT. <br /> NAME TITLE <br /> OFFICE USE 006 <br /> SWEEPSM 0DMP M [OCCODE fjXTCODE:MACnVH UGl M offimpT'UGI' MCLOSED UG'I' SWEEPS PRGM/SUIi CY:)Dh 0XI'I; <br /> i <br /> I?H 2!U44(1?J86} <br />