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Underground Storage Tank Program - Farm TankTnformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUST ESS NAME _ CONTACT NAME <br /> A L ox /o �rn: K <br /> C ADDRESS(Street address of TANK locate n) PHONE# (with area code) <br /> I <br /> L <br /> I CITY, STATE <br /> SSTTATE ZIP CODE NEAREST CROSS STREET // <br /> T 7,4jeti L a-. i ` c i " (6 <br /> Y CIIECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAME OPEERKI OR CONTACT NAME <br /> P L /0 r�rtS �iLt i ? (a <br /> E MAILING or STREET ADDRESS OPERATOR PHONE k with area code) <br /> R G. �O L7- 3606 <br /> A <br /> IYZ <br /> T CITY STATIi ZIP COUE <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 CONTA, N4ME <br /> ( <br /> 0 /Jev� ✓ G R�D SC / [a i kL DR C oR 0 ✓a <br /> W MAILING or STREET ADDRESS OWNER PHONE k(with area code) <br /> N <br /> E IP //,'6A17 <br /> R CITY STAT[ ZIP CODE <br /> (:a. <br /> 9�a3 <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATI;BOX <br /> I ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y AL1,underground TANKS at site = toot < 1,100 gallon capacity) <br /> P EXEMPT FARM'CANK SITE ( g <br /> E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet if needed.) <br /> T TANK SIZF CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PRFVIOUSLY IFCURRL'NrLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N d <br /> K <br /> ( ice Uej Lau <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TIIE BEST OF MY KNOW LEDGE,IS TRUE AND CORRECT. <br /> NAME 27 47 TITLE , DATP.. 7 'w <br /> OFFICE USE ONLY <br /> SWEEPSM I COMPM LOCCODE DISTcODCNACTIVE UGT MEXF:MPT UGT NCIASED UGT SWEEPS PRGM/SUB CODE DATE <br /> EII23044 (12/88) <br />