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submttel Numder 93 G56 Date Received 01 /20� � <br /> Site Code : I779I24 <br /> Site Names <br /> CO <br /> CO Lead Agency : LOG <br /> Address : 1645 N CHARTER WY Contact : SONNY SHIPNA�H <br /> City : STOCKTaI tip: 9`J2U6 Phone : 209 466 5086 <br /> Billing/responsible Party Information <br /> Billing Name: Bill Info OK? <br /> Address: <br /> City : State: zip: <br /> Contact : Phone <br /> ( Property Owner/Operator <br /> Name : Phone: <br /> iAddress: <br /> City: State: Iip: <br /> Client Information ( if different from Owner / Operator ) <br /> Name : phone : , <br /> Address : ti <br /> City State : Zip : <br /> Applicant ' s name , date signed , title <br /> Date : <br /> Name : y <br /> Title : OM REPORT _ <br /> Consultant Company : ARTESIAN ENVIRON <br /> Contact Name : Phone : <br /> Other Contact name or Info : Phone : <br /> i <br /> L F( rogram Element : 3:.x26 Billing Code : , <br /> Assigned To : LT <br /> Title of Submittal : QM REPORT <br /> Date of Submittal : 01 / 20 / 93 OT Request : N OT Request Date : <br /> y Type of Submittal : 9 Quarterly Report / Post —Remedial Monitoring <br /> t. Permit Fee paid (1 . 00 y <br /> Check aidNo . / Cash <br /> Date Paid <br /> 1 <br /> Permit Fee Paid O • 00 <br /> �) Check No . / Cash <br /> Date paid <br /> Staff Review Due : <br /> OT Scheduled : OT Completed : <br /> Action <br /> Date Action Date Action Date ` <br /> Add . Info Srp Due <br /> —� <br /> Ack / Com Ltr Req PR Due <br /> Ack / Cam Ltr Recd Repor e w Cir _ �2 <br /> �J J ) Par Due <br /> RWQCP Comments Repor e w FRP Due <br /> Othr Agency Appr ( File / <br /> ' <br /> Add . Info Recvd <br /> � i) Fnied Revision Due <br /> rmit lse. .ied : 0th Agency Due <br /> Permit Type : Special Pe <br /> � Wrkpin Revw Comp <br /> Comment Ltr Sent Project Complt <br />