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INITIAL INFORMATION FORM FOR UST OWNER/OPERATOR <br /> HIGHWAY AUTHORITY AGREEMENT FOR ', <br /> LEAKING UNDERGROUND STORAGE TANK SITES i <br /> Requirements generally: Any owner/operator requesting that the City of Decatur enter into a II <br /> Highway Authority Agreement shall submit the following: <br /> Applicant Information <br /> UST Owner: Svendsen's Service Center <br /> Business Address: 3696 Greenswitch Road <br /> Decatur, IL 62526 <br /> Telephone: . . 217-875-2200 <br /> Fax: <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 Siqn for Owner: <br /> Name and Title of Person Authorized to Siqn for Operator (if different): <br /> Applicant's Attorney(optional) Environmental Consultant <br /> Name: Company: CW3M Company, Inc. <br /> Address: Project Mgr: Vince E. Smith, P.E. <br /> Address: 701 W. South Grand Avenue <br /> Telephone: Springfield, IL 62704 <br /> Telephone: 217-522-8001 <br /> E-mail: E-mail: cwmco@sbcglobal.net <br /> Street Address and Description of PropertV Adiacent to the Impacted Riqht-of-Way <br /> Property Name or Description: Svendsen's Service Center <br /> Street Address: 3696 Greenswitch Road <br /> City: Decatur Zip: 62526 County: Macon <br /> Riqht-of-Way(s) under City of Decatur iurisdiction requirinq Aqreement <br /> (Check one or both) <br /> Highway Number(s): �Soil Impact in Right-of-Way <br /> Street Name (if any): Greenswitch Road � Groundwater Impact in Right-of- <br /> Way (potential) <br /> � <br />