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Section 3. Other Insured's Information Chock this box If this section does not apply. <br /> Other Insured entity name <br /> Relationship with applicant <br /> Other Insureds type of operation <br /> *If more than two(2)other Insured entities are requested,submit the above underwriting information for each additional entity. <br /> Section 4. Location information <br /> Location Name Location Identification Number <br /> Address I chack box it same as applicant address <br /> City _ <br /> Contact <br /> Telephone Fax <br /> Emall <br /> Type of Operation Number of years location has operated as such. I <br /> Location owner ASame as Applicant Location operator 0 Same as Applicant EJ Same as Owner <br /> El Other: [3 Other; <br /> Mon i kl'-J <br /> —L"J No Location <br /> ❑ 1, Have them ever been any reportable releases and/or pollution claims for bodly Injury, property damage, or <br /> cleanup costs including, but not limited to, claims by private persons, public entities, governmentai agencies or <br /> other third paries at this location? If"yee,provide an explanation and attach copies of applicable reports. <br /> Z. Are you aware of any waste materials that have been disposed of or buried on or at the location? If"yes". <br /> provide details. <br /> 3. Do you have a Spill Prevention Control & Countermeasure (SPCC), Emergency Response or Storage Tank <br /> Management plan for this location? If Iyae,attach a copy of applicable documents. <br /> 4. Are there any abandoned, temporarily out of service,empty,out of use or inactive storage tank systems at this <br /> iocation? If'yes',provide details: <br /> .If coverage for more than one(1)location is requested,submit a completed Section 4 for each additional location_ <br /> CqAvt <br /> L <br /> C <br /> EWG5T1McGw0710 A BERKLEY COMPANY <br />