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TRANSACTION SCREEN QUESTIONNAIRE <br /> Page 5 of 5 <br /> Copies of the completed questionnaire have been mailed/delivered to: Anderson-Barngrover, Siegfried,Engineering, Inc„ San Joaquin <br /> County Public Health Services-Environmental Health Division Robert McClellan <br /> Preparer represents that to the best of the Preparer's knowledge the above statements and facts are true and correct and to the best <br /> of the Preparer's actual knowledge no material facts have been suppressed or misstated. <br /> 4 <br /> r d3 �i61 <br /> Signature Date <br /> ..,9� lI?ONr1f r4h <br /> NP <br /> �F v <br /> No.06305 <br /> i * Expires:04 0 <br /> • � NB <br /> i <br /> f <br /> I <br /> G:NoatalG ROUN DZEIPHASE 1 Isiegandtgs.doc <br />