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1 <br />t <br />1 <br />1 <br />1 <br />-4- <br />ADDITIONAL INFORMATION <br />This space can be referenced for further information of any of the items in this form. <br /> <br />To the best of my knowledge, all the information presented in this application is true <br />and correct. <br />Date• September 27 ~ 1985 gy• ~,~,y .5 ~IG~i <br />c <br />Owner <br />1t e <br />(Signature by individual legally authorized to <br />bind the operator to this application) <br />(Rev. 4/84) <br />Doc. No. 5547 <br />