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APPLICATION FURlti1 \� <br /> PLEASE COMPLETE THIS <br /> A - APPLICANT <br /> HIS PAGE ONL Y- PLEASE PRINT OR TYPE <br /> Applicant Name: P17 c-J <br /> 77) <br /> Underground Storage Tank(UST)Cleanup Fund Claim Number: I L<G�' If <br /> Site Name &Address: Cl�� P� 7 <br /> Mailing Address (if different from above): 'Cg nY .� 21 - <br /> Phone <br /> 1 -Phone Number: 707—7 dj Fax Number: <br /> Name of the Overseeing'Regulatory Agency: �Z►'� ' G, <br /> Name and Phone Number of the Contact Person: l ��_3�(� <br /> =ATTACH THE PRELIMINARY SITE ASSESSMENT REPORT, AND AINY OTHER DOCUMENTS <br /> FNTONSTRATE COMPLETION OF TAE FOLLOWING ACTIVITIES, IF APPLICABLE: <br /> OF,OR APPROVED ,MODIFICATIONS OF, EXISTING TANKS(In the space provided belou., <br /> is work and indicate x•here it is described on your attachment.) <br /> � `N OF PETROLEUM-SATURATED SOIL OR RE�NIOVAL OF EXCESS PETROLEU►I FRO61 <br /> SOIL WITHIN THE TANK PIT.(In the spaceprovidedbelox, summarize this work and indicate where it <br /> n Your attachment.) / <br /> ' t i 1vf �^ �.j? <br /> v <br /> 3. REMOVAL OF FREE PRODUCT(In fire space provided below, summarize this work and indicate ix•here it is described <br /> on your attachment.) <br /> �. <br /> Please read,sign,and date the following statement. <br /> flLL SIGN,¢TURES MUST BE ORIGINAL NO REPRODUCED OR COPIED SIGNATURES WILL BE ACCEPTED_ <br /> The undersigned does declare under penalty of perjury that all facts and statements set forth as part of this claim <br /> application are true and to the best of my knowledge and belief. <br /> Executed at <br /> on — Zrj 19 <br /> Ai\JSignature of Cleanupl Fund Claimant <br /> Print,Ya e <br /> Page I of 1 <br /> SWRCB SRA Form(Version 1/97) <br />