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JAN-29-2003 12:07 GLACIER ENVIRONMENTAL r.06i06 <br /> ttvthlt i,rKUV11):U 1UMhUKMY K11-rLA11VC• <br /> Sr3 <br /> hc. <br /> BUSINESS NAME: GoCL �u"}er' -l-zbtucl � <br /> (!jApplicable) <br /> OWNER/OPERATOR: r^ <br /> De IU i vin D 7- E&ve," Env;rOn me-4al Ma ha <br /> (Please Print) (Title) <br /> /-30-03 <br /> (Owner/Operator Signature) (Date) <br /> ADDRE S: P, 0' Sox 71/ <br /> (Mailing Address) <br /> �a lhs Tx 75 22 / - 07// <br /> (City) (State) (Zip Code) <br /> PHONE: ( Zo$ ) 2 <br /> EH 23 046 (Revised 1/24/02) <br /> 7 <br />