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Underground Stot Tank Program - Farm Tanfiltfo do Form <br /> FACILITY/SITZ:INFORMATION(Complete this form for each FARM' NIC location '{ <br /> FFARM or DUSINESS NA CONTACT N <br /> -� � <br /> A o t <br /> C ADDRESS(Street address of TANK location) __ Pt10Nf;'i� (with'arga code) <br /> ' ao s - <br /> L 4 �( 0 1. I �c , o4) <br /> I CITY II /STATE ZIP CODE NEAREST CROSS SIREET <br /> T � 7OC t`tt `)/ �5' GF--) > C, <br /> Y " CHECK HERE if this ADDRESS shuuld 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# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP C011E <br /> O <br /> R I CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROI'ERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME, OWNER CONTACT NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY S7'A'IT I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P MEMPT FARM TANK SIZE (ALL 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 udditional tank information on separate sheet if needed,) <br /> T 9'ANK SI'!.E CI IEMICALS STORED ESTIMA7£D DATE 01ST USL:D METHOD OF CLOSURE DAIS OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PIUiVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> ( CCS I C <br /> K <br /> dC <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN C MPLETED UNDER PENALTY OI-PERJURY,AND TO TILE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME DATE <br /> OFFIO SL ONLY <br /> SWI?EM N COMPO IAC CODE DIST CODE N AC1'I Vf-'UGT N LXEMPT UGT N CLOSED UGT SWEEPS PRGM/SUE CODE DATE <br /> VI-123 044(12/88) <br />