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Underground SOW-age Tank Program - Farm TanrInformation Form <br /> FACILITY/BITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BNAME _ CONTACT NAME <br /> USINESS <br /> A )4�' <br /> C ADDRESS(Street address of TANK location <br /> I ) PHONE N (wit6 area code) <br /> L l <br /> I CITY SPATE I ZIP CODE NEAREST CROSS STREET <br /> TL—I ? <br /> Y CHECK HERE if this ADDRESS s ould be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS ' ° OPERATOR PHONE N (with area code) <br /> R <br /> A <br /> T CITY STATE ZIP CODS , <br /> 0 <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 CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .I. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (AIL underground TANKS at site - to or < 1,100 gallon capacity) <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 S17F CHEMICALS STORED ESTIMATED DATE LAST USED METIIOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N � <br /> K 1 � I'J/ <br /> ���� <br /> I C1Zv�tloer �9 <br /> N <br /> F <br /> O <br /> TINS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME _ TITLE DATE — <br /> OFFICE U Ority ` <br /> SWEEPS# ODMPO WCCODE DISTCODENACTVEWT NEXEMPTUOT I#CLOSED DOT SWEEPS PRGM/SUB CODE DATE <br />