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5u mt a M"Mner• `,. -Ib1 ate eceive E <br /> Site Code: 9040 <br /> Site Name: CALIFORNIA FQS (VACANT) Lead AgeJ7 <br /> Address: 838 MOKELUMNE ST Contact <br /> City: WOODBRIDGE Zip: phone: <br /> Pilling/responsible Party Information <br /> Billing Name: Rill Info OK? <br /> Address: <br /> { City: State: Zip: I <br /> Contact: phone <br /> Property Owner/Operator <br /> Name. Phone: <br /> 3 Address: <br /> City: State: Zip: . <br /> Client Information (if different from Owner/Operator) <br /> Name: Phone: ! <br /> Address: ! <br /> € City: State: Zip: <br /> Applicant' s name, date signed, title <br /> Name: Date: <br /> ! Title: <br /> t � <br /> Consultant Company: AEGIS <br /> Contact Name: Phone: <br /> Other Contact name or Info: Phone: <br /> Program Element: 2960 Billing Code: Assigned To. MM <br /> z <br /> Title of Submittal: SITE ASST REPORT <br /> Date of Submittal: 02/09/93 OT Request: N OT Request Date: <br /> [Type of Submittal : 3 Assessment Report <br /> Permit Fee Paid 0.00 <br /> Check No. /Cash <br /> !1 <br /> Date Paid - t! <br /> Permit Fee Paid 0.00 <br /> Check No. /Cash <br /> } Date Paid !� <br /> Staff Review Due: OT Scheduled: OT Completed: <br /> Action Date Action Date Action Date <br /> Ack/Com Ltr Req Add. Info eqstd Srp Due <br /> Ack/Cam Ltr Recd Rev is'a s ed -PR Due <br /> RWQCB Comments �Repor. v Comp �r Due <br /> Othr Agency Appr Fil N .n, 3+o�.q3 &- Due <br /> Add. Info Recvd Dere Revision Due <br /> Permit Type: Special Perini Issued: 0th Agency Due <br /> Wrkpin Revw Comp Comment Ltr Sent Project Complt <br />