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1� <br /> St SPENSI0'� 7F WORK APPLICAT=11-`-lN FOR.lti1 � p <br /> :PART A : APP. LICANT <br /> PLEASE.eD1ti1P ETE.'THfSP GE.OIVLY'= PLEASE;P LVT'OR T'YPE. .:. <br /> Applicant Name: VA t e <br /> Underground Storage Tank (UST) Cleanup Fund Claim Number:. ��7 <br /> Site Name& Address: U1qCL - <br /> ` X,721,v X07 3 <br /> Mailing Address (if different from above): <br /> f�- <br /> Phone Nuritbef'" - <br /> Name of the Overseeing Regulatory Agency: <br /> Name and Phone Number of the Contact Person: <br /> ATTTRS 'RLLIIA1D A 'S� TH DOC` NI1vTS <br /> T >: t?I5TRA' ' `C011P .E'1IC { ATI ' `. Pavt �E. •.. <br /> 1. REMOVAL OF, OR APPROVED MODIFICATIONS OF,EXISTING TANKS(In the space provided below, <br /> summarize this work and indicate where it is described on your attachment.) <br /> 2. <br /> EXCAVATION OF PETROLEUM-SATURATED SOIL OR REMOVAL OF EXCESS PETROLEUM FROM <br /> SATURATED SOIL WITHIN THE TANK PIT.(In the space provided below, summarize this work and indicate where it <br /> is dgscribed on your attachment.) _ n <br /> G-F // A <br /> . I <br /> 3. REMOVAL OF FREE PRODUCT.(In the7snace provided-below, summarize thrs work and indicate where it is.described,_, <br /> on your attachment.) A <br /> :I <br /> Pleac;read,s€gFr, d data the frslowing statement <br /> :.. <br /> ;4L Sl'Gi1t 'f1RES.MfIS '.B QRIGf1aC;4L IYO.RE >FLE)�ffCB?.O}i!CJPL< .SIGITURS LL:BLc `CP ....... <br /> The undersigned does declare under penalty of perjury that all facts and statements set forth aS part of this claim <br /> application are tr and correct to the best of my knowledge and belief. <br /> Execute on G-` �1tNL ` f 19 ,) 7 <br /> Signature of UST Cleanup Fund Claimant .-Print Name <br /> Pa,ae 1 of? SSVRCB S4tl�! Form(Version 1/97) <br /> k <br />