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Eligibility Application <br /> NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY <br /> DIVISION OF WASTE MANAGEMENT <br /> UNDERGROUND STORAGE TANK SECTION <br /> PETROLEUM UNDERGROUND STORAGE TANK CLEANUP FUND <br /> Instructions <br /> Submit this application to access the Commercial State Trust Fund. The application must be completed by the owner/operator of the <br /> underground storage tank(s),or landowner. Submit an application before seeking reimbursement. Altered or incomplete applications will <br /> be returned. Please send in the original, signed document, as copied applications will be returned. If you have any questions,please call <br /> 336-776-9688.When complete,mail application to: <br /> DEQ <br /> DIVISION OF WASTE MANAGEMENT <br /> UST SECTION <br /> 1646 MAIL SERVICE CENTER <br /> RALEIGH NC 27699-1646 <br /> I. Supporting Information <br /> 1. Facility Name Lee County Public Works Fueling Incident# 42234 (Include any prior incident numbers) <br /> UST# FA-8003 (Include any prior UST numbers) <br /> Facility ID# 0- 0000035056 Site Priority Ranking Undetermined (Obtain from regional office) <br /> 2. UST(s)site address Street 617 S Fifth St <br /> City Sanford , NC Zip 27330 County Lee <br /> 3. Name of applicant Lee County General Services <br /> 4. Name of current site occupant(s) Lee County General Services <br /> 5. Name of current landowner(s) Lee County General Services Date Acquired 9/15/1992 <br /> 6. Last owner of UST(s)while in use <br /> Name Lee County General Services <br /> Contact Russell Spivey E-mail russell.spivey@leecountync.gov <br /> Street 805 S Fifth Street <br /> City Sanford , NC Zip 27330 County Lee <br /> Phone (919 ) 718-4622 ext 5380 <br /> 7. Last operator of UST(s)while in use <br /> Name Lee County General Services <br /> Street 805 S Fifth Street <br /> City Sanford NC Zip 27330 County Lee <br /> Phone ( 919 ) 718-4622 Ext 5380 <br /> 8. Name of consultant to be copied on correspondence <br /> Name Terraquest Environmental Consultant, P.C. <br /> Contact Ryan D. Kerins E-mail rdkerins@terraquestpc.com <br /> Street 100 E Ruffin St <br /> City Mebane , NC Zip 27302 County Alamance <br /> Phone (919 ) 563-9091 <br /> 1 DWM/UST V.8/1/l9 <br />