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�-07k2/2004 15:32 2054671118 AGE STOCKTON PAGE 02/0 <br /> ELECTRONIC SUBNH TAL PASSWORD AUTHORIZATION FORM <br /> FOR CREA'T'ING CONSULTANT'S AS AUTHORIZED RP AGENTS <br /> FACILITY GLOBAL if)#; <br /> TANK OWNER,OPERATOR,OR RESPONSIBLE PERSON AND ADDRESS' <br /> fed F CPA-I(F/, <br /> FACILITY/LEAK 5i'TE ADDRESS,� CITY �� STATE ZIP CODE <br /> —Me above idcntiftcd responsible person does hereby appoint: <br /> DESIGNATED AUTHORIZED REPRESENTATIVE NAME.„ <br /> ROBERT MARTY <br /> COMPANY NAME: <br /> ADVANCED GEOENVIRONN ENTAL <br /> COMPANY ADDRESS CITY STATE ZIF CODE <br /> 837 SHAW ROAD ST04CKTON C.ALEFORNM 95215 <br /> To apply for a password for the electronic submission to the C cerracker database of laboratory and location data <br /> pertaining to the facility/sitc idcntiiicd above. <br /> I hcreby agree and fwrtber authorize the above-named designated authorized representative to ccrdfy that the applicable <br /> state rcoatory requirements pursuard to Article 12,Chapter 16(Underground Storage Tarek Program►Regulations) <br /> California Code of Regulations,have and will be complied wia <br /> 1 hereby agree and further authorize the above-named designated authorized representative to allow to other persons who <br /> have collected for the above-identified facility/site to use the password to electronically submit data to the GeoTracker <br /> database. <br /> This Authorized Representative Designation shall become effective on the daze of execution and shall remain in effect <br /> until terminated,in writing,by the above-named responsible person. <br /> EXECUTED THIS DAY OF P 20 <br /> AT <br /> tSPO STBLE,PE ON SIGNATURE• AUTHORIZED REPRESENrAT1'vE SXGNATURL <br /> ROBERT MARTY _ <br /> PRINTED NAME PRINTED SIGNATURE(209)467--1006 <br /> ' <br /> PHONE NUMRER �_— PRONE NUMSER <br /> To begin electronic data submittal process, obtain <br /> Password and login at: Mail or FAX to: <br /> htt :II eotracker.swrcb.ca. ov/ab2886. Deanna Fianagin <br /> Connection may take up to a minute as the secure SWRCB—DCWP <br /> � <br /> site is established. Please accept certificate to P.O: Box 944212Sacramento, CA 94244 <br /> allow process to continue. Mail for FAX completed FAX: (918) 341.5808 <br /> and signed form within 2 weeks. <br /> AUTHORIZE FORM(AUruS72001) <br /> I <br /> I <br />