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�, � t <br /> .i � , <br /> T <br /> CITY OF DECATUR <br /> INITIAL INFORMATION FORM FOR UST OWNER/OPERATOR <br /> HIGHWAY AUTHORITY AGREEMENT FOR <br /> LEAKING UNDERGROUND STORAGE TANK SITES <br /> Requirements generally: Any ownerloperator requesting that the City of Decatur enter into a <br /> Highway Authority Agreement shall submit the following: <br /> Applicant InfoRnation <br /> UST Owner: Martin 8� Bavlev, Incorporated <br /> Business Address: P.O. Box 385 <br /> Carmi IL 62821 <br /> Telephone: (618) 382-2334 e�. 260 <br /> Fax: l618) 382-8956 <br /> E-Mail Address: <br /> The UST Owner is doing business as (please check one): <br /> ❑ Sole Proprietorship ❑ Partnership�Corporation ❑ Trust or Estate <br /> ❑ Limited Liability Corp. (LLC) ❑ Government entity ❑ Other <br /> Operator(if different): <br /> Address: <br /> Name and Title of Person Authorized to Sian for Owner: <br /> Bryan Williams: Consultant/Professional Geoloqist <br /> Name and Title of Person Authorized to Si�n for Operator(if different): <br /> Same as Above <br /> Aqplicant's Attornev(optional) Environmental Consultant <br /> Name: Company: Applied Environmental Tech. Inc. <br /> Address: Project Mgr: Jav Emerv <br /> Address: P.O. Box 303 <br /> Telephone: Carmi, IL 62821 <br /> Telephone: (618) 382-8232 <br /> E-mail: E-mail: aet98C�D_midwest.net <br /> Street Address and Description of Propertv Adiacent to the Impacted Ri�ht-of-Wav <br /> Property Name or Description: Huck's Food and Convenience Store No. 167 <br /> Street Address: 3595 Larkdale Court <br /> City: Decatur Zip: 62526 County: Macon <br /> �ht-of-Wav(sl under Citv of Decatur iurisdiction reauirins� As�reement <br /> ( eck one or both) <br /> Highway Number(s): �oil Impact in Right-of-Way <br /> Street Name (if any): Larkdale Ct, Tanaqer. �Groundwater Impact in Right-of- <br /> Whiqpoorwill Way (potential) <br />