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Part 6— STATEMENT AND SIGNATURE <br /> A. Statement and Signature. The undersigned affirms that the information contained in this <br /> application is true and accurate to the best of his or her knowledge. Please note that someone other <br /> than the Customer may sign this Application Form. <br /> Name: Jacob Letts Title: Project Manager <br /> Signature: _ Date: February 6, 2018 <br /> Organization: GeoEngineers <br /> Mailing address: 1101 South Fawcett Avenue <br /> City: Tacoma State: WA Zip code: 98402 <br /> Phone: 253-722-2419 Fax: E-mail: jletts@geoengineers.com <br /> B. Affiliation. <br /> What is the signatory's involvement at the Site? Please check all that apply. <br /> ❑ Customer <br /> ❑ Property Owner <br /> ® Consultant <br /> ❑ Attorney <br /> ❑ Other— please specify: <br /> If you need this publication in an alternate format,please call the Toxics Cleanup Program at 360-407-7170. Persons with hearing loss can call <br /> 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. <br /> ECY 020-74(revised May 2013) 16 <br />