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1 LMt. 11 1J YKUVlllhll 1U Mb UK MY KhYKhJhN1A11Vh. <br />BUSINESSNAME: Jim Thorpe Oil,Inc. _ <br />(If Applicable) <br />OWNER/OPERATOR: <br />Same as above <br />0 <br />(Please Print) ( t <br />Jim Thorpe Oil'-- Inc. b --— Vice President <br />------ -------- Y -- - <br />-- --- ------------------------ <br />(Owner/Operator Signature) (Date) <br />ADDRESS: P.O. Box 357 <br />(Mailing Address) <br />Lodi, CA 95241-0357 <br />(City) <br />PHONE: ( 209 _� 368-6175 <br />EH 23 046 (Revised 1/24/02) <br />(State) (Zip Code) <br />7 <br />