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<br /> 4, pte ;e tWe on prim Way all ..c, noted
<br /> S. Lse a ha,r, point x5,E.9 t,7.H, mml x Ocr ram ,t<sl ing 3 OTM
<br /> TOP OF FORM, "MARK ONLY w),Nl,' 1,T,-,o['
<br /> hem tAt but dc.x,:°i[ar ,he mason the hkill O(roh., c(3,potd,.
<br /> uAtninTisnu
<br /> 1, IZc t res l nme €rI° e%of€vW.€u ottm) of On: undergaind tank( ) «
<br /> 1111,1 1Id+1,t6..a .alt. tin <2 �_.i �`(pp������&,'kkt;tt€u($kic'<'tti�an in.��a "in chyv ;�t a, and zip "i.>de,
<br /> OX NiJiMBESS ARP,
<br /> Indus , nearest c, street .and mume of the (Tcramr,
<br /> 2, Phone nenifetr niust have an at a lade. If the night nuliftcr is ,he imintc ,`€site "SAME" in t'i-per bocarion,
<br /> 3, ,',h k- the. appruprkai .lox Or TYPE P (W 13t,I.1\1 S i.)WNEJR1HP (". C"(7Rl't3f1N'L'ON, 1NipR`11 UA! , cu.)
<br /> , (:'huk the .pis,€,S;°E,. 1,>,, ":I`blif OF 11L SINFSS.
<br /> 5. 1�f' adUty/S sir L.,.a t re; .rvao,rt _ _,c 1 a., t,, � s, ..,_ box, inn t_. , .,,
<br /> I �ndicaw Tr, ,
<br /> 7. Mmwd We ERA. 1D 0 or Wo "IRAlf in
<br /> 11" 11 11 F-SE'I"v OWNER ADI &mss: % 1.,11" x
<br /> ("'in ,here as,1 a€.t,sc in who SUAM, umco av _m.:; am we am ac; S, a r if ,,. same. W.,. SANG! AS 1 111
<br /> AtSt.CC6 m Be ..,a,.., to "..1,..... k ... ,a_, a.I.Ha F)ri, oc.,
<br /> 111" 1ANX OWNFI FORM .IUN dt= a=D,.R ',xn °,r1Uk1 B C 1az1P1.111 lr,
<br /> (°€ spletealt hems A it $ef.t0n, un ss X11: ftrmis am dw same as Sl;(71„T0i 1; If the same, n-t"€te "SAW AS IWI17 acrAs,
<br /> this se stham Besure to check TAN WNE IIIA,r ISI?trey,
<br /> I % WI OF :< LJt I XZA 1`ON`LKI°tt°1rFORAGI?1 U!, (,'CO NTT' NI MBIA€ UsM BE . 1 I4, 110
<br /> 2 uer,ymr I3csns. of E xneil,r",",:..t (MAO ( roc €"z, fee acc,rinil +,t x_"lses a,ltich is required tamom 1€.;qtr pormit aprdo,oion
<br /> can lir: proemsei Registrallis , Ah We MAE wiR w.,um thm you W rsetleom a uirvnly stooge fee mum in repo,. 1, A",
<br /> r£1.ttN ((s "Ho pu ga<&n he ,Wsr on the rimriber t,. gallons placed in ticc.r r Ula Thi BOE nits code persons f.,;c,,.W s,mi
<br /> 'raging Me Std age we so z;,.aims AD Wit he vomit H )4U do nol h".Ev an ,e..t'unt h.2itnbci Ath ',he B01', or ifyou ha t,, a nr
<br /> questions regarding the f e.. or pt ase ,, the HOF,, 9l6-32,3-9555 or 1Szire ha the }1(71 at thc,,foll iG°£#g icnJt ssS
<br /> Board of Iiqmltpa2... P,(), 113tvc ),,Ilr:`,`, CA 914279,0001,
<br /> ?' "1'1�I31.;1tJ`t l °I1��r��{(:1rSIa 1�I�1r���f1I111I:fI°,1' �SaI.>.�"°I11�1�(IItI1r11.I`1T1��
<br /> Identify the me ht2 (s) used by Beowner andpr €p`nvor tar nacaming ,he a aderxr and State fuitr€cltl rcsricnisibilmy
<br /> r lrair°etncross T ra1,s €rs"sc r by my Wera0 ca-Eaam agercy Are r "n Earn ;his ri r.dre mint.
<br /> ' ,@g�@ yF ,§X(,w1g}(cF,RggS.:gY+4.'n&�bi.�i.�bsg�..AND
<br /> the address 3�2iS. +€4. Tq' c,.a, R.T
<br /> Ig'63 A'.£ig....F¢S-t�4reykp`-�;�4`f[iJp�.9LXgyevYgd'#3g'gF. d'4..1�f�,.�`�gu.c�<S3�L r 1 H! 'A,`'�}CCN s'S 2��k.I(AI q.ls`),
<br /> INFURUi..,S,.XON FOR THE 1. 1, R SR,'FE#NrFy�S`
<br /> 'I't,e c£rrrnty and Ica2•`€I,c .a>-_ n,Wxs n am praleterritin ad and can be c1a,aahted by r,2l hg Me We Luted s'W107Nr751, '1111C
<br /> 46E t'3U2Yslier may be antriad ,y the ica! „5g n€y„ LJ"`r`cm„ AN , ,ub rats( be ,ikota L.YicaJ and e.an 1£54 L°t'.Snlana .,.n
<br /> c:c}7t3 illezteA Ia Me jonat aVnq preNs .die r„-°.e Board t ra,,,E.�,a d , ca,.r, number, please 11116 a.ve :t L'5l.,nk,
<br /> IRTS'I'I 3 SUIRUNNUMIXIT ia1 110i (s(AL rnk lfi ?1 f1���P 1...1.° ,t,1tN "1'1`1
<br /> ( °1.'111. t 1:a WRYI"� 171:IF
<br /> AWMRACY OF T111l IN 111 MA1.,01b,. IIHS APP1.I1_:N110,.aa t.rraS;fdt"I°1 11I PR 11.',1S1J I1°°.1 BI FINE,AUDUNNI,
<br /> UMBER IS Ns1' 1`111.20 IN. 1111:1-.1 (,"r LGUINW 1l 11I':r;f"11 51111a1f 8311 1111? �; fl'1,f:1'1C1 (Hr'1111"
<br /> 'I XAL (:sl NC N' I.1SU, ONI.N' 11 F0Jk1M."1'1 0fq BOX AND Ir(111.'FOS AIG)I1 G ONE 121.11 I " AND
<br /> ATAXIAT1 1k)R-, 'B'(s)TO 'FHE E 1°11's'101WIr (1DI), f"RS,
<br /> SD
<br /> IVII1 O (A1"1tt1III11IS
<br /> E:y 1 S. _I:.I::¥I
<br /> ..` P.O,,13OX 527
<br /> PARAMO? I', CA 9072:$
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