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E 235► �` <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK �J <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 90o <br /> (Check one item only) ❑ 3 RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION 305 <br /> TOTAL NUMBER OF USTs AT FACILITY 904' FACILITY ID# <br /> 3 1 (Azencv Use On! <br /> BUSINESS NAME(Same n FACaM NAME or DBA-Dong BuYnm An) } <br /> FedEx Ground Packa e System,Inc. <br /> BUSINESS SITE ADDRESS fol. CITY <br /> 120 S.Hansen Road Trac <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408, <br /> FedEx Ground Package System, Inc. 412 262-7375 <br /> MAILING ADDRESS 409. <br /> 1000 FedEx Drive <br /> CITY 410. 1 STATE 411 •ZIPCODE 412- <br /> Moon Township PA 15108 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42s-r PHONE 428.2 <br /> FedEx Ground Package System,Inc. (412)262-7375 <br /> MAILING ADDRESS 4283 <br /> FedEx Ground-Environmental Services,1000 FedEx Drive <br /> CITY 428.4STATE 428-5 ZIP CODE 4296 <br /> Moon TownshipPA 15108 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415, <br /> FedEx Ground Package System, Inc. (412)262-7375 <br /> MAILING ADDRESS 416. <br /> FedEx Ground-Environmental Services, 1000 FedEx Drive <br /> CITY 417. 1 STATE +te. ZIP CODE 4w. <br /> Moon TownshipPA 15108 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4za. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 3 1 9 1 8 1 9 1 2 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> acb. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein i ue accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425 <br /> 7h f S 412 262-7375 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE a27 <br /> AnthonyS alvieri Assistant Secretary <br /> UPCF UST-A Rev.(122007) <br />