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Dec 2-013 <br /> puj, t r,,_ GA <br /> —A Date Name of Property Owner Address where work was performed type waste gal.pumped disposal site N <br /> — 0 <br /> a � <br /> 12-(Co 0 m 52i Sl 1'P0 O <br /> w - , W i" So X15 ZZOO 1 qU <br /> 1)--i a X54 S So 5 asp it tk (0 ob << y <br /> 12-1 cP-q tos '" res - - t;—>00 `t <br /> ti 2- '-%L43 s &v-6a <br /> ' 1 -23 G >4, t aA G�WoLcaa s2D" IWO <br /> Z R Sys res {toflv L` L b <br /> _ ��ff �+ H <br /> Z I ala 5 S LrjY�Q-� ZDO <br /> Z- 1 (o i D Paaute. ) qt-�—qml 0 U D <br /> Z i5 5 t�ckYiG,r-t �C s23f 12-s i <br /> S R , <br /> 0 <br /> Co <br /> 0 <br /> 0 <br /> The following excerpt from the code of Federal Regulations.Section 4ff3 QReport must be signed by a corporate officer who can legally bind <br /> the company" I certify under penalty of law that this diocument and all attachnwnts were prepared under my direction or supervision. <br /> b <br /> W <br />