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San Jequin County Environmental Health 0artment <br /> DATE11 —11 6-03-2015 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> ',1 /�� SITE MITIGATION <br /> SIL• AREAS f EHD USE O O NOA <br /> ER IDC /DOZ`t/�L)D CABE g UNIT IV <br /> OWNER FILE:ComPLETEPROPERTYOWNER/RESPONSIBLE PARTY/NFoRMAnonr.• CHEDRH• OWNER CHRREAfTEVONFREWHEHD � <br /> PROPERTY OMNER NAME CARL GOWAN <br /> ( 201 836-2482 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME EIMAIL ADDRESS <br /> Carl Gowan cariCcDqowanconst.com <br /> Owner Home Address <br /> 15 West 8th Street Suite C <br /> City STATE ZIP <br /> Tracy CA 95376 <br /> Owner Melling Address <br /> same as above <br /> Melling Address City State LP <br /> Ay same as above CA 95376 <br /> YJ CORPORATION ❑INDIVIDUAL El PARTNERSHIP El GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FAcILIWID• INV# AccouwID PRVRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_OTSC_EPA_ <br /> FACILITYFILE: COMPLETE BUSINESS/SITE/PROJECT/NFORMAT/oN: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES p( NO r❑y <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No I <br /> BUSINESSIFACILTUI$RE/PROJECTNAME Heinz Facility(Former) <br /> SITE ADDRESS I PROTECT LOCATION SURE# BUSINEMPNONE <br /> 1447 Mariani Court(Lot 9) 209 836-2482 <br /> CT STATE LP <br /> Tracy CA 95376 <br /> BOARD OF SUPERVISOR DISTRICT 5 LOCATION CODE KEPT KEYz <br /> Meiling Address HDIFFERENTTf»m Fed//tyAedress Attention:or Care Of(opflons/J <br /> 15 West 8th Street Suite C Carl Gowan <br /> Melling Address Clty Tracy STATE LP 95376 <br /> SIC CODE APN# //5—O ^T /0__nCt COMMENT: <br /> THIRD PARTY BILLING INFO: Cofnp/ete/f Billing Party is different from Property Owner or Responsible Party identifiedabove. <br /> BUSINESS NAME Advanced GeoEnvironmental, Inc. Attention:orCare Of topnonal/ <br /> Mailing Address PHONE <br /> 837 Shaw Road 800 511-9300 <br /> CITY STATE LP <br /> Stockton CA 95215 <br /> 9G2aNdRAooaEsS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: Lthe undel5igmal.Applicant,cetfifl'that Iam the(toner,Operator,Aathorfzed Agent,or Respam"iMe Parry and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,EMbRCEM£NT CHARGES aad/Or HoUR/.YCHARGES'aseawi ted with this pmjM will be bitted N meat the address idenhRed above as the ACCOUNTAD assn;for this Site. I also rertify that all <br /> information provided an this application is true and earrect:and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and SrAIE and/or FEDERAL Laos and Regulations As the undersigned Owner,Operator,Authorized Agent.or Responsible Party for the prom located above under facility/ste address.I <br /> hereby authorize the release of any and all results,repor6,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> is available and at The same fime it is provided to me or my representative. <br /> APPLICANT NAME(PLEAeE PRINT) Robert Marty SIGNATURE <br /> i' <br /> TITLE President-AGE TAX ID# " <br /> APProwd S Deb Aluountl Oma Prooaealn#Completed B Be. lP <br /> $ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECENED BY WORK PIAN PE <br />