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Underground Sto ;e Tank Program - Farm Tani 'iformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BU S NAME CO =ME <br /> A Oh —4 it �J`tM <br /> I <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 1 9906 <br /> T C � lOG��� 6� ZZOS NF,A@EST'CR SS STREET <br /> 5�57Y ICHECK HERE if this ADDRESS should 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 CODE <br /> O <br /> JR1 I 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#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERD if this ADDRESS should be use r I Lgj Notification <br /> CHECK APPROPRIATE BOX <br /> .I. ACTIVE FARM TANK SITE (One or morc 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 site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet if needed.) <br /> T TANKSIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATEOF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMVIT IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FORM 1IAS EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO ME REST OF MY KNOW LEDGE,IS TRUE AND CORRECT. <br /> NAM TITLE DATE <br /> OFR CF SE ONLY <br /> SWEEPSN I COMPN I IOC CODE I DIST CODE#ACTIVE UGT #EXEMPI-UGT #CLOSED UGT SWEEPS PRGMSUU CODE DATE <br /> EH 23 044(12/88) <br />