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Underground Stora 'ank Program - F rm Tank I�iCOrmattan Form <br /> FACILITY)MTE INFORMATION(Complete this form for each FARAI TANK location.) <br /> It <br /> F FARM or BUSINESS NAME CONTACT NAbdE <br /> A Gig"� ! , �C� 4!5 '/t J-z <br /> C ADDRESS(Street address of TANK location) PHONE IV (with area code) <br /> �Gq <br /> L <br /> I CITY STATEZIP CODE N LEST CROSS STRCEr <br /> T e.- Z; <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notifcat ion <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> I <br /> 0 NAME OPULkTOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PRONE# (with area code) <br /> R <br /> A <br /> T CITY STATE LIP CODE � <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notificatio . <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME OWNER CON'fACf NAME <br /> 0 i <br /> NMAILING or STREET ADDRESS OWNER PHONE 11(with area code) <br /> E <br /> R CITY STATE I ZIP CODE j <br /> CHECK HERE if this ADDRESS should be used for LegalNotificatio <br /> CHECK APPROPRIATE BOX <br /> ,L. ACTIVE FARMTANK SI'T>r (One or more underground TANKS > 1,100 gallon capacity) <br /> y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at sitemoved r closed in place) <br /> I <br /> UNDERGROUND TANK INFORMATION (List additional tank Information om uparate sheet If needed.) <br /> T TANK SUB CHEMICALS SHRED ESTIMATM- DATE LAST USED M13-MOD OF CLOSURE DATE OF (GMOVAI l( <br /> A (OALLoNS) C URREMI-Y OR PREVIOUSLY 1F CURRENTLY r:MPT'Y IF PERMANEN'17.Y CI-CkSED CWNUIUL IN PLACE <br /> N <br /> K <br /> N <br /> F <br /> O <br /> TIAs FORM Hm3prkCO UNDER PENALTY OF PERJURY,AND TO TIi REST OF MY KNOWLEDGE,IS TRUE AND CORREsCT. <br /> NAME nTLF — /,G.� DATE S S <br /> OFFICE USE a Y <br /> SWIMPS M COMP 11 LOCCOD@ DIS'1'CODE MACIIVI:UG'1' M UCrMPT'UG'I' 9CLUSED UG'I' SWI IIIIS IARGKSUB CODE DA'M j <br /> I <br /> EH 23 044(12/88) <br />