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Underground Stora Tank Program - Farm Tank luzormation Form <br /> FACILITY)MTE INFORMATION (Complete this form for each FARW TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> C ADDRESS(Stmct address of TANK location) PHONE# (with area code) <br /> L <br /> I CITY STATE ZIP CODE NlWtEST CROSS STREET <br /> T <br /> Y CHECK HERE if this ADDRESS should be used for Legal Nolifica tion <br /> OPERATOR INFORMATION &ADDRESS (Complete if Information different from above.) <br /> O NAME OPURATOR CONTACTNAML: <br /> P <br /> B MAILING or ST'RM ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STAT11 'LIP CODE <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notificati n. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE if(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notificali n <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TAMES > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> $ PERMANENTLY CLOSED FARM TANK SPIE (ALL underground TANKS at site 4move closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank information rin separate sheet If needed.) <br /> T TANK SIZE C HEMW-US 9110RED ESTIMATED DATE LAST USED METHOD OF Cl URE DAT E OFtF1vlOV It <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IP CURRF.NILY EMPTY IP PERMANF-WrLY CLOSSED CLOSURI-IN I'L ACI: <br /> N �►v+ <br /> K 67CD7 61 to � O o <br /> N <br /> F <br /> O <br /> nm FORM nm3p&CO UNDER PENALTY OF PERJURY,AND TO 71 EX BST OF MY KNOWLEDGE,IS TRUE AND CORJUX—r. <br /> NAME TITLE — G.� DATE V g <br /> OFFICE USE o <br /> SWUM M COMP I LAC CODP DISTCODE K ACIIVls L)GT M EXEMPT UG"1' CL.()SED UG'I' SWEEPS PRGM/SUB LDOE UA'Ili <br /> ` LSH 23 044(12J88) <br />