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UNIFIED PROGRAM CONSOLIDATED FOM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4w <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION �3v(os <br /> TOTAL NUMBER OF USTS AT FACILITY 404' 1 FACILITY ID# <br /> 3 A n U9e On <br /> BUSINESS NAME(same n FAcnm NA9ai aDBA-Doing eacnns a) }. <br /> FedEx Ground Package System,Inc. <br /> BUSINESS SITE ADDRESS im. CITY 1a. <br /> 120 S.Hansen Road Tra <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or +os. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust Iands7 ❑Yes Z No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME +or PHONE 409, <br /> FedEx Ground Package System,Inc. (412) 262-7375 <br /> MAILING ADDRESS <br /> 409. <br /> 1000 FedEx Drive <br /> CITY 410STATE 411 ZIP CODE 412. <br /> Moon Township PA 15108 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42PHONE 4x2 <br /> FedEx Ground Package System,Inc. (412) 262-7375 <br /> MAILING ADDRESS 4x&9 <br /> FedEx Ground-Environmental Services, 1000 FedEx Drive <br /> CITY 4z STATE 4n-s ZIP CODE 42M <br /> Moon TownshipPA 15108 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 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 411, 1 STATE 419. ZIP CODE 419. <br /> Moon TownshipPA 15108 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K)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. 621. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 411 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certifv that the information provided herein i ue accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE I DATE +x+. PHONE +xs. <br /> a <br /> 7 l S 412 262-7375 <br /> APPLICANT NAME(print) 4M. APPLICANT TITLE 427 <br /> AnthonyS alvieri Assistant Secretary <br /> UPCF UST-A Rev.(1212007) <br />