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---tea <br /> SITt MAP <br /> ATTACH A SITE MAP DRAWN TO SCALE WHICH INCLUDES A NORTH ARROW AND DISTANCES RELATIVE TO THE NEAREST PUBLIC ROADS. <br /> REGULATORY AGENCY <br /> LOCAL UST PERMITTING AGENCY SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> REGIONAL WATER QUALITY CONTROL BOARD(RWQCB) REGIONS V <br /> LEAD AGENCY PROVIDING OVERSIGHT OF CLEANUP (1)RWQCB a (2)LOCAL AGENCY a (3)JOINT <br /> LEAD AGENCY CONTACT PERSON HARLIN KNOLL TELEPHONE NO. 209-468-3442 <br /> SITE HISTORY <br /> IF THE CLAIMANT(UST OWNER/UST OPERATOR)IS ALSO THE PROPERTY OWNER, <br /> LIST THE DATE THE SITE WAS ACQUIRED MONTH_MARC DAY_I_ YEAR_1 Z7�_ <br /> IF SITE WAS ACQUIRED AFTER 1/1/84,IDENTIFY PERSON(S)FROM WHOM THE SITE WAS ACQUIRED. <br /> NAME <br /> ADDRESS <br /> TELEPHONE NO. <br /> IF SITE HAS BEEN SOLD,LIST PARTY(IES)TO WHOM IT WAS SOLD AND THE DATE SOLD: MONTH DAY YEAR <br /> NAME <br /> ADDRESS <br /> • TELEPHONE NO. <br /> IF CLAIMANT IS FILING AS UST OPERATOR ONLY,LIST DATES OF OPERATION: FROM: To: <br /> PROVIDE THE FOLLOWING HISTORY OF THE PROPERTY OWNERS,UST OWNERS,AND UST OPERATORS OF THIS SITE. AT A MINIMUM,PROVIDE <br /> INFORMATION FROM THE DATE OF UNAUTHORIZED RELEASE DISCOVERY TO THE TIME OF THIS APPLICATION SUBMITTAL. <br /> TIME PERIOD PROPERTY OWNER UST OWNER UST OPERATOR <br /> FROM: <br /> NAME NAME NAME <br /> To: <br /> ADDRESS ADDRESS ADDRESS <br /> FROM: <br /> NAME NAME NAME <br /> TO: <br /> ADDRESS ADDRESS ADDRESS <br /> FROM: <br /> NAME NAME NAME <br /> TO: <br /> ADDRESS ADDRESS ADDRESS <br /> FROM: <br /> NAME NAME NAME <br /> To: <br /> ADDRESS ADDRESS ADDRESS <br /> UST CLEANUP FUND CLAIM APPLICATION(REV. 5/97) PAGE 3 <br />