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�,�" <br /> AREAU DERGROUNZzz <br /> AGE TANK -o' DATE �-� ��-7 7 <br /> DBA PHONE2,6 I- I <br /> ADDRESS - CITY <br /> OPERATOR C d �5 PHONE <br /> OWNER ` �L. t c e5 " 'd j�-cU�'►�. r'� c . PHONE <br /> M <br /> ADDRESS -2 1 9 t c�U � r-c U c, �40 <br /> '• <br /> BILLING ADDRESS �, <br /> CONTACT N• t C-IC. c5 PHONE q3 <br /> ADDRESS �� e <br /> ARP! LOT SIZE HORT TERM APCD PERMIT <br /> WATER PURVEYOR SANITARY DISTRICT <br /> FACILITY TYPE LC SEPTIC _ � WELL <br /> TYPE I22 3 4 5 TYPE 1 D3 4 5 TYPE 1 3 4 5 TYPE 1 2 3 4 5 <br /> �\ TANK #-___i_ TANK # -)-- TANK # TANK # <br /> STATE I cl�D 0 Lf�0 0 STATE ID J L 014UG-STAT I D t't0 2 a 0 ,3 STATE ID <br /> PRODUC ` PRODUCT RP ODUCT PRODUCT <br /> SIZE Od SIZE p 00 SIZE v D66 SIZE <br /> PIPING , PIPING ` PIPING PIPING <br /> MONITOR MONITOR _- MONITOR S MONITOR <br /> i <br /> d5 — <br /> 4D bt v dtdt r� l f q <br /> UST 24 6/86 <br />