Laserfiche WebLink
.:.. .. ...... ....:);Mi::i:l::.>:•N:::::i:::::::is T:4T:..••{..... ...:....... .:...........::': ........:n^iT'ff................r"':T.l:....... <br /> .....:.. :.. r::....:r. ........... .:. ..../.. .. .....rr....n...n........ v.........•::::::::::::::..rr..nyl.v:...r;:yi:{.:.:..... v..::: <br /> y <br /> r:J.•.T <br /> • 4 <br /> All claimants, including all joint claimants, must sign and date this Claim Application. If the claimant has <br /> authorized a representative to sign on their behalf, documentation to this affect must be submitted by the <br /> r claimant (e.g. Power of Attorney, signed statement from the claimant). All signatures must be original; <br /> no reproduced or copied signatures will be accepted. <br /> (WE) HEREBY DECLARE UNDER PENALTY OF PERJURY THAT ALL FACTS AND STATEMENTS SET <br /> FORTH AS PART OF THIS CLAIM APPLICATION ARE TRUE AND CORRECT TO THE BEST OF MY(OUR) <br /> KNOWLEDGE AND BELIEF. <br /> EXECUTED AT. <br /> ON THIS 2 D DAY OF No�ew►bei 19 "t <br /> WANT'S SIGNATURE <br /> I Lo V, <br /> PRINTED NAME <br /> CLAIMANT'S SIGNATURE <br /> PRINTED NAME <br /> JOINT CLAIMANT'S SIGNATURE <br /> PRINTED NAME <br /> ,PINT CLAIMANTS SIGNATURE <br /> PRINTED NAME <br /> DELIVER COMPLETED APPLICATION TO: OR MAIL COMPLETED APPLICATION TO: <br /> STATE WATER RESOURCES CONTROL BOARD STATE WATER RESOURCES CONTROL BOARD <br /> DIVISION OF CLEAN WATER PROGRAMS DIVISION OF CLEAN WATER PROGRAMS <br /> k UST CLEANUP FUND PROGRAM UST CLEANUP FUND PROGRAM <br /> 2014 T STREET P.O.BOX 944212 <br /> SACRAMENTO,CA 95814 SACRAMENTO,CA 94244-2120 <br /> r <br /> {REVISED 1/941 <br /> (SEE FACING PAGE FOR INSTRUCTIONS) PAGE 13 <br />