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This company purchases such oil from the following vendor(s): Name: Address: Name: Address: Name: Address: Name: Address: I declare under penalty of perjury under the laws of the State of California that I am authorized to legally bind Claimant and that to the best of my knowledge and belief the following statements are true and correct: 1) That the information provided in this form is complete and correct and 2) That Claimant has operated in compliance with all Federal, State and local requirements pertaining to the management of this oil..

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