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JOINT CLAIMANT AND CO-Pt.AEE STAFF USE <br /> IDENTIFICATION FORM <br /> III. JOINT CLAIMANT <br /> I <br /> ©NO-PROCEED TO THE NEXT SECTION <br /> A W THIS CLAIM APPLICATION BENG FILED JOINTLY? <br /> .i YES-PROVIDE THE FOLLOEING INFORMATION FOR EACH JOINT CLAIMANT <br /> S.JOW CLAMANT NAME O JOINT CLAIMANT STATUS(CHECK ONE) <br /> MAAJNGAOMSS ❑SEAMIDUAL ❑LOCALACENC/ <br /> OTY.STATE ZPCCOE ❑PARTNERSHP ❑CCIMORATION <br /> TELEPHONE NUMSER ❑JONTVENASE ❑CTHNI: <br /> ( I <br /> 0. TAA i0ENT6iCATION NO, C CONTACTP6IS@I <br /> F. F RUJG AS THE 0016H ON OWNER AMID OPERATOR OF THE TANK(q: <br /> OATS SITE WAS ACOUMEO: <br /> OATE SOLO IF APPLICASIA: PERSOMM SOI)TC: <br /> PPSON(S)SITE ACOLFI®FROM OF AFTIA I/IMI: <br /> NAME: ADOREAL. PHONE F. <br /> G. F FUNS AS THE OPERATOR PUT NOT THE OWNSIM OF THE TANR(SN: <br /> OATES OF OPERATION TO <br /> jPEASON(S)THAT OVREO TANKS)CURING FUSCO OF OPERATION <br /> FROM: TO: HAAS: AOOIESS: PHONE A' <br /> IV. CO-PAYEE <br /> ❑ NO -PROCEED TO THE NEXT PAGE <br /> A IS A CO-PATEE TO BE NAMED IN PAYMENT OF THIS CLAIM? <br /> YES -PROVIDE THE FOLLONNNG INFORMATION FOR EACH CO-PAYEE <br /> it <br /> & CC-PAYEE NAME <br /> MAPJHGAOORESS <br /> CITY STATE ZF COCE <br /> 7 <br /> IEP7 <br /> NO. 7AK IOENTF1GAp1 NO.: <br /> (NEW 119V 'AGE 2 <br />