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r OF WORK APPLICATN FORS <br /> 4D-- - <br /> APPLICA1 <br /> �. SUSPENSION F <br /> , <br /> t ! <br /> RT.A` :T7 <br /> �ErSE° eQ PETE IS 4GE 4.N�Y PL ASE�'R �VT'D Z TYPE . <br /> Applicant Name: <br /> > � � 7 7 f? <br /> Underground Storage Tank (UST) Cleanup Fund Claim Numb <br /> V <br /> �Z�L— L� 'lf ` SI E 1J),flu <br /> Site Name& Address: _ 3 <br /> 4 - r <br /> Mailing Address(if different from above): r ,� <br /> Phone Number:' �14 Fax Number: <br /> T� a�`3 <br /> t, i A� (�O(L'1J /yS.CN G�lOf2/YY-ir7/iL I ► » -1Y <br /> Name of the Overseeing Regulatory Agency: <br /> Name and Phone Number of the Contact Person: .57 <br /> !77 77 <br /> 777.77117 <br /> AT "AGH <br /> MIN ASSESSMI�IT itEPORT,A�1D ANY flTH> R DOLU.MI✓NT5 <br /> Tt D IVIQI TRA E e-omPI ETI "T,"i. L-OWI G. ,CTIV ITIES `APP IGt S • .... < <br /> i. REMOVAL OF,OR APPROVED MODIFICATIONS OF,EXISTING TANKS(In rile space provided below, A. <br /> summarize this work and indicate where it is described on your attachment.) k� <br /> 2. <br /> EXCAVATION OF PETROLEUM-SATURATED SOIL OR REMOVAL OF EXCESS PETROLEUM FROM <br /> SATURATED SOIL WITHIN THE TANK PIT.(L: the space'provided below, summarise this work and indicate where it <br /> is described on your attachment.) ' <br /> Vic? i'.>� <br /> � t <br /> space provided below, summarize this work and indicate-where it is described <br /> ;. REMOVAL OF FREE PRODUCT (In the <br /> on your attachment.) E <br /> 7 <br /> Please read,stgs,and elate the fes;;offing statetnt <br /> W tLBE-A�c�� :...., <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 a and correct to the best of my knowledge and belief. ' <br /> orti , i G f3 �i 1�'Y1Lt.. <br /> 19 `I <br /> Execute <br /> Signature of UST Cleanup Fund Claimant w Print Name <br /> SWRCB SWA Form(Version 1'97) <br /> Page 1 of'. <br />