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AREA UNDERGROUND STORAGE TANK DATE <br /> DSA <br /> PHONE 3 5 f5 JC� <br /> ADDRESSCITY <br /> OPERATOR PHONE <br /> OWNER 12 e PHONE ?3, - ,21 <br /> ADDRESS 6 14o _ r o 3-3 66 <br /> BILLING ADDRESS 1-7 <br /> CONTACT PHONE <br /> ADDRESS <br /> APPA � V/V LOT SIZE SHORT TERM APCD PERMIT <br /> WATER PURVEYOR SANITARY DISTRICT <br /> FACILITY TYPE SEPTIC WELL <br /> TYPE 1 2 3 4 5 TYPE 1 2 3 4 5 TYPE 1 2 3 4 5 TYPE 1 2 3 4 5 <br /> TANK # �� �• TANK # �" TANK # TANK # <br /> STATE I D J ►'� STATE 10 " - STATE ID STATE. ID <br /> PRODUCT Evn RODUCTy-U.1 ODUCT PRODUCT <br /> SIZE ,SIZEJ SIZE SIZE <br /> PIPING PIPING PIPING PIPING <br /> MONITOR MONITOR MONITOR MONITOR <br /> 0 <br /> 4 <br /> L <br /> r IAti-L r 1{ G / <br /> 1 <br /> rirr n. C !UC <br />