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STORAGE TANK POLLUTION. APPLICATION
PL E—Ai& ANSWER: Ad QUES - 77ONS C I OMPLE . TELY
NSTRU 0%. This application( is to be -used when applyi.ng for Storage Tank Pollution coverage. Ple
ase corm livable ete all ap ica e
sections of -thit'sapplicat n., Read.. questions -caref lly and provide complete and ac -answers "r ". lurefo or
curate. ai
ride complet
K e
-or d'n'al 'of coverage. Th' ap .not an
accurate: iMformation may resukin dela, ed �qonsiderati' n of appl'i 'tion
p, this ca
ication is�, -Y p!
Cerra any n5 gp res apt rea' I f ad diti onal
insurance licv and the C . ' co id0i.qg:.cqVe,.a, reserves--Ahe right to reject any
PQ P �4ppliqation-.:-for _Q y. son.
space is e en de d -please, atta-ch-. -.details tothis applicat I idn -:on ar �e arate :piece of paper- �All appli-cantsf. i d -date t
p Must s a n: sign
d 0. p [i ca- t io 0 Wh ere, -(r,t hated
NOTICE: .F6 certain oli i6� and 0a ants pthe lirn
1. bJlity av8ilable to a ju dgmnts:' 'Ottlenobtsshall be
n -for logal.defense. Pu. 'I d against the
redUced by-.:�irnounts I cc Oor note:' incurred for le at defense shall.: -a
that arn6unts
PP aga:
deductible or self -insured retention -amount.
ALL -APPLICANTS MUST SUBMITTHE FOLLWING INFORMATION IN ADDITION TO-THt:'COMPLETED APPLICATION:
-A f—
'S m-m1st. etompieted-rorea
1. Tank. -�h4duleAddeh&m'. i b7 each location 'a'n-'-dtarl,k.'.s'e'ek'ingccover A*&',e.
2. '8tom ge tank a nd line irate gcity test resuits. dated Withinthe last iWelve (12) months,;
3. om other sto ra ge to .. n ,p ete copies k b-'r line testihg. or Monitoring results;
4. 'Cbmp:e.te copies, o any .ex,piringstora.getank --�t lic.y,,,including unatteted doblaratio'ns dn'd all eb",doirsem—ent's,
5. 1)6taited, informa-fion regarding anv Prior releases. remediation o.r-Planned tank upgrades or-rebtacement.
APPLICANTRAME'
Ghant CdumtvD AT
611V202*5
ADDRESS:
5C: tNW, PHONE:
5W 754-2.. 11: CITY: STATE _WA. ZIP: 989-21 tMAIL:-
:
ENTI'T'Y'-tS':.',E3'1-nd'i'vid"ua'I El Partnership, E3 Corporation Cl Joint Venture . (3:tL"6- . 190ther '(01eiase Expl'ain) WEBStTE:
Yea'r1tr'.`t_ 0'-.d':- 1996 A0 DBordth M �f, : Ihtu a S -
Requested tff ive D'a"Itia:,
3/7Y2.3
4cy,t.errq
Re4ituasted Limi.-Its d_fjnsui_r.'anc'0!:
-1--0()0,00-(y[1A�0,000
Re'Uested Deductible:
q
Ni:Schid�e,
Effective. Date: Retroactive Date:
Carrier: Qa & Foitei Prem4u'm:
Limits: 11000, 11. .000. beductibte:
Has the a.pp norhaveariyofthe.subj ctf ` iiiii e or storage ta'nksl ever had ahytype -cif
Ton or-h -8 such "k 0 1.1 "d for'a-R`yj as anya U
orage afifi.;.. in'suraince- c. verage c. ncel.e. cationTor
13 YES' M NO
insurance-ev-er- bent denied?
Facility Name facility Address Number. of U Number of ASTs Facility Operations
Grant Corm Pubii� Wada 124EteqfiseRd 1.2
*11 a dditionallqcilities are seeking coverage please continue this list W_ ith- all required biformation on a separate sheet of paper.
THE STORAGE TANK SCHEDULE ADDENDUM THAT IS ATTACHED TO THIS APPLICATION MUST BE COMPLETED IN ITS
ENTIRETY SEPARATELY FOR EACH FACILITY S HOWNA80VE.
Storage -Tank Application (1121) Page 1 of 4
a,. —. _ .:.. . S. c .. __ :x=. , _. _.- __. _ ...-- ...... r_ _.. .:.,_-.c _ .: 7_.... _. _i.r� S -'.c., - _ -
Q R-J, M .... _ 5-T!
...V-7-R
t+
c Lo th. at[ current
1-An��- aft tanks -in regulations?p. an..
_6p
YES ENO
ease.providefuff details separarly
2., Does the: applicant have any open or pending notifications to any local; state orfederat implementing
agency.,
13 YES 0 NO
f gkdse'pravide full _det(3i�S: Se pq
��`Md'� o'd
YES 0. NO
(If phase- provide full detdih separqt'e[�*)
p
4.-'Are 1' h*ere.�any additional tanks at this to cat"ion that are not described above. or in attached -schedules?
13 VO
YES IN
(if IITWI. please p.rovidi--fdll'd6falfs-separat6iy)
5.."W_ '6r6 611 sf orage tanks 'new " a'..'the 't`irn6`"6f thoirinstallatidn?
.
"
91 YES NO
(if #N�o please p .s rovide-full. detdilsepdratefyJ
.0
6 ; Are there any plans to close in, place, temporarily cl ose, upgrade -or remove any storage -ta n ks! at any. fa ci lity
in the h `6 118
ei(teig teen oht s.
0 YES 91 NO
ff `W P*16dse....
7.Haxreydu-rebEIWe'',requested orothe -Miseined any.est'matepropos6ls-o- M& to reIace -rove or
close any.storage tanks wifhiq the past twelve ('12) months?
%YIEll S M 140
full fUl
pleases provide.- detai s.separate[y)�
re eases, spiels r other -pollution events' af-this 0'-r,
9. HaV__'e':t'h,ete.e:ver. - een�any-,re"p"-Q'-r*'t"'abie' - "k0' any 01, ier
owP',". . opera e'd/ ted facill.t
E3 YES @1 NO
'(If-"Yes"'7-pletrse-provide--fLilI details separately)
t _y
9'r,Have ap storage tanks been removed or Closed" in place at any, of -the subjec
13 YES NO
(if le ProVide. full d please sepatate
e �611§ ly,
16&Wfh`;n.`jhe` ast_-,i�elv-e2 m ont Kshas any on -site e 'onijotihS e11 o,rs_y.sj em. s own.an increasein
Cobt'a
m. na0lev'Ols?
0 YES IS. NO
s?'- please prow d' tcyffs,�eparately}
(if `*e, e
11. Within the past twelve (12) months,has: any sheen: of -free product observed :bserved in -any surpps cpllars
spill bU&,t, or contain Meat?
.0 AS [Ir No
t in'the past tw, rn lnt 81 hasany ential.�ontam a'on een suspec e( y odor,
or- vapor or
vapor te-s. J.ng7
0 YES NO
f.�YeSf,, please.providef Ulf d'6talls separate
1KAFe all sforagptqnksadtive and in use at'thetime of corn p'leti n this
. - tapplicaflo'?
'-e'..�-'O*'fa'na*t.i*cin
IN YES 13 NO
(if Na please provide' a.detailed separately)
1. Has"the applican'tb(any p "'er'so'n-o*r**6ntit.y."--8'poI..ying asari. nstibM ever filed or been the subiett-of any -
bankruptcy, receivershipor insoh/ency proceedirtgs?
0 YES M 'NO
provide full detaiis.separdtieIyJ'
2. k.1he" tAm'e'of s`i-g n-i nig this app. application., is --the- apiplicah"t -a W -are of a'n' y'incident, event, occurrence ac I
dr , cum*stanc( or I situ ., ation-'thadt t:duld reasonably result in a claim or suit, demand. or irequiriernent-forcleanup
E3 YES NO
being made against it ter an other en�it y y for Which coverage is.being.sought?
(fflyes" please -provide full details separately)
. I . Have any . ehvi rQ . n mental or pollutlo'h claims or suits ever been m-ade a.ga,inst the applicant or any.other
Tor ahtltyl- W'h 'rc'h:- coverage is being $ought?
0 YES NO
(if YY' s q, please prdvid8 full details separately)
which e
4,Has the apapplicant, -or ari"y ot hi er enter n sought, ever'had a reportable release or
p for Hch coverage is being g
spill of any regulated substance, hazardous materials, or any other pollutant, as defined by local, state or
0 YES M. NO
federal enivi ro' hm'' ehtafl s-tattit.es or- reguhtions?
f p y)
ff "Yes" please provide Lill detalls separately)
5. Has.there'ever been any violations; complaints, injunctions, contamination, rernedia on, ti corrective action
o r m 0 nitof i ng'. at an y ci I ity W" ed r
'fa corned o operated by the applicant -or any other entity'for whic-h coverage is
YES 0 NO
being sought?
(if "Yesqpfeasa provide full details. sepdrately)
Storage Tank Application (1121) Page 2 of 4
NOTICE TO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance uran.ce or statement of C'18i M- containing any materia'lly'false information o, - r, conceals, nceals. fbrfhe purpose of misleading, inifibfrn- ation con
cerning any
faft material thereto, 't 6*mn'jits, a fraudulent insurance 'act, which is.1-a dir'be and shall afls'o be su'blectt6 criminal and civil penalties.
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly ;presents a false or fraudulent claim for.payment Of a loss or benefit or who
kn'0'Swin,gl resents informati on in an 'application f6 t insurance i y pre, ent n rance -9 g'uilt' ` f a crime and maybe subject to res*tituti6n fines
-yo e or confineme, n
priso, or any c0 'ion thereof.
.n' mb.inat
NOTICE To ARKANSAS., NEW MEXICO AND WEST VIRGINIA APVLICANTS:A4y person h__k .. ... . Iv presents a. failse� "' 4 - claim f
p. r h w o nowing. or rduduleht c a or
P-a'y:me'nt of a loss or benefit, or khbWin presents false information -in an application pplicationfor insurance is,guilt yof a crime and may b&*s bject to fines
and. confinement -in prison..
NOTICE TO CALIFORNIA APPLICANTS: Any person who knowingly presents -a false or fraudulent :iclai for the payment of a loss Is gu
ifty-of A-crme-
and may be subject -to fines -and.confinemen-t' in state prison.
NOTICE TO 'COLORADO APPLICANTS.- It is unlawful to knowingly provide falls i fete or- mf8leading facts or ii form-6tii n- o - an; insurance
e, incomp, o t
com any-fori-thie purpose 6 f defrauding or attempting o. defraud the company: h -n-is- n-me- t fines d6nial of insuran ce 0 e B t mpany. Pe alties' may include iM'p' o. n
..of
c' 6 m' -ce�c h- k 1. id ME misleading ding'
an qvi damages. Any insurance an or agent. an mblete, Or m* i
insuran. qmp�qny,iv -o:, nowing,.y provi es se, inco s a facts or
to defraud the policyh holder or laimant _,wirth -tegard to- -a
ihfo r rmtio n: to a poli Elder cl'aima'int for the pu'roose of:de*fra--ud'i"ng.6r.atte'mp�i g.o r c
cy n
settlement or -award e. from, insurance proce.ed.s.shall be reported to the Colorado Division cif Insurance w - ithin the Department of Regulatory
k6t; h. €� e i t i e s.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:. Wa.ming: It is a crime to provide false or misleading information ti to an insurer for the purpose of
defrauding the insurer rahy`other pe'rso h. Penalties in.clude."imprisonment and or fines. In addition. an insurer may denyJ nsu-rance benefits.; if
false inf6imation- eriaIf yrheilaitedto a 'Claim *was provided by' the a, plicant.
. mdt"J' ` . I .. .. y p
NOTICE TO FLORIDA APPLIUNTSiAny -person, who knowin- g! iy wind with n w intent to injure, defradd or deceive any insurer files a statement claim
of m
orari app'lidatidi tontaring anyfalse, ineorrtpfete ga
r a.tio.ni§.g'Uilty A a, f6l6rV -Of the.third de ee.
NOTICE TOXANSAS APPLICANTS: Any person -who knowingly and with intent to defraud, presents, causes to be presented- or prepared with
kfid"W'ledge or,belief that it, Vvillbe ` 'e'rited to or by an insurer, purpbrted insurer- b�6k'er*-'o"r-'a''n"'y'agdfit�h'erelof -.6ny writteri,-i 1. dt electronic Pros. o e e , r0nic,
im'Pul.so-', facsi mile rn.z!gn,etiq Oral br'ti�,I.i�.phoni.c.com.mun.ication or: statement as. part of orinsu port of. an application for, thei,�suance of or:the
_p.
rating of an insurance :policyfor personal or.commerci-al, insurance, or . -a claim for payment or other benefit' pursuant,to aninsurance olio for
commercial or perso,nal. insurance which such person knows to .contain material falseinformation concerning any -fact material thereto; or conceal's
for': the purpose of MiMeadi*ng, information concerning, any'fact material thereto Commits a fraudulent ins . urance act.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowiny and with intent to d4faud any n insurance company of other person files an
mi . sl e - a. .. i ng fo atio h� ari-y fact
a ri - riformatio- conceals f6r the: ouhjo d' in- tm
applica ion for insurance containing ' iall' false iii n. or con ea s se of
y mater y concerning
material. thereto -commits a.fraudulent insuranceact,-Which is..a crim
e.
NOTICE TO LOUISIANA APPLICANTS: Any person W- h-okn6win presents a false or fraudulent. c-laim for pa*y'men*t of A loss of .benefit or, k'n g1V `owingly
presents fafseinf6rmati6n in an applitdtionforinsurance is guilty cif-a''c'nme and ray b(�_,' bjecttofifies-arid confinement in W risen.
p
NOTICE TO MAINE APPLICANTS: lt--is a crime to knowingly
'provide.false, incomplete or misle6 ding information to an insurance company for'the
purpose of.defta6ding the compan' Penalties may include fines or -a denial 6finsdi-86cebenefits:
NOTICE TO MARYLAND APPLICANTS-. Any p-erson who knowingly Or willfully presents -a false or fraudulent.claim, for payment of a loss oe benefit or
who knowirigly or willfully presents false information in an application for -insurance- is guilty of a crime a''
91 y and may be subject to fines and
confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person' who files a claim.with.. intent to d r Lid helps commit fraud again- 8-f -an in'sur'' ' oruilty of -
of a .. or e er is g a
crime.
NOTICE TO NEW JERSEY APPLICANTS: Any person who include's any false
or misleadin information on an. application for an insurance poliy is
subject to criminal and civil penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person -fi[es an
application. for insurance or statement of claim containing- any materially fats e:info rmation, or conceals for -the purpose- of misleadingi information
any material n which is a crime and shall also be subject to a civil penalty not to exceed
concerning a I thereto., commits a fraudule't insurance act,
five thousand dollars and the stated value of the claim for each such_ violation.
NOTICE TO OHIO APPLICANTS: Any personwho, with intent to defraud or knowing ihait he is- facilitating a fraud against -an insurer, r, submits an
application or files -a claim containing a false or deceptive statement is guilty of insurance . rau f ` d
NOTICE TO OKLAHOMA APPLICANTS: Warm . ng: Any person who' knowingly, arid w . Ith . intent to in.j ure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading in -formation is guilty of a felony (365:15-1-10, 36
§3613.1).
Storage Ta n k Application (1121) Page 3 of 4
NOTICE TO OREGON APPLICANTS: Any person who knowingly art her p
d.with intent -to defraud -any insurance company or other erson. files -an
a :'licatio-n-f6r insurance -.or statement of claii containing; a" alIV, f�lse iff6rinafion or, conceals, fo-e the purpose hfcf ma-tioin-
pp any maten. pose of mislea ng, i r
may be guilty,6f a. fraudulent act. tVhich 'be a crime d y subject such concerning any f materials thereto ., -
act m may me.an ma uc persQn'to, criminal and civil
Opp, . q'It.i.6's.,
NOTICE TO PENNSYLVANIA, A P PUCANTS: Any �persqn: Who kn- gl wt owin y8hd A'h ihte-nt-to, defraud a'n-y- insurance co.mpaftybro''th"
er p.erso file an_
.
tic insurance b r ��§tzit nt of cla'i' m tbhti4ini -any rn�teria lv-. faKia inform Is fo -th' s f 'i for ation'
a p -aii0h for r�g r ation or r e purpQ..e o m is
leading 'infor
concerng an fact.materi.6.1 th.ereto commits a fraudulenfibsurance aft, 'hich is a crime and subjects such
W
person to criminal and c' 'I vendities.
NOTICE TO TENNESSEE.. VIRGINIA. AND WASHINGTON APPLICANTS: It � is a* & irni�..to kn
owirighi -provide; false Aete or;
!,nr Nle�odihgjnfo .omp rh.. rMation
to an insurance company -for the purpose of defrauding the company. P en-alt i0s i h"clude. imen . t fines and den Oal of i ns
irnpFisor
urance benefits.
NOTICE TO VERMONT APPLICANTS: Any : ets6rf_Aivh0,-knowingIy presehtsaialse statement, in . an -.a ca ion for" 17110be w1w of -a
insurance
criminal'offense and subject bjec*t to penalties ies under stiate. law.
WARRANTY-STATENIENT: This ap J' appli it pu.rchase, oT:'the comp.an to issue any i" ince but it is- a this
p icatio.n.does not bind the cant -to Y nsurw
greed that
application sha'-If be the basis of the co . iitract should a, -policy be issued and it will beattached to and made paft of policy.. The undersigned
6pplicnht declares that (-s')he:,is,;a 6thorized by th e* ap' lit cant t this plication' on- -b e-half of 'all
p a . o, �ign t isap prospective insureds and that; -tb-the bes' of
hWher*nbw*ledge,, the-uat e*rpeints herein_ are true and ac.cUrate. The applicant �i�gr tees: -that if information supplied inthis-80 i ion -and the
_ a p] cat. n.
materials submitted therewith S'houl'd change beiween-the date this application is signed . and t the effective d . aie ofthe the proposed- the
-insurance
hall immediately. `h' d M complete up ate.orcorrect .. the
signatory s notify the insurer such an shall provide with information that wou d
erms o - r c -6 coverag . e c o'rdin* ly:.
1i tion and -Is submitted ther' ith. The'in-sur r "'ithdraW.- or modi-N� ab'ny-6f the b ohdiiiQh§.- f
6pp ca ma, a eW e. may w .
a c
Storage Tank Application (11 21) Page 4 of 4