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• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 5-3-2013 MASTER FI C � D INFORMATION"MFR" GREEN FORM <br /> _ �u ` SITE MITIGATION&LOP <br /> _ ,s}(,'yv +�s.`: " •{.Ai:�•.-. .... .. _ <.0 '- :+-`i7, ;fix....: <br /> SNADEDAat<Aa PO1sEHD ueEON�y ` wNSR/DIF"4; � -''- b'•�'":Y„ •tin•:• I UNIT IV <br /> s :OAEep v' <br /> :P' li=s'`�S-Z'iti T�Gs�*r"� �s?i�-��:Pii: •�,•;,yl..-� `� t��. <br /> OWNER FILE.COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. ONEONIPOWNER/YOURRENTLYONF/LEW?N EHD El <br /> PROPERVOWNERNAMII Westlake Chemical Corporation (713 )690-9111 <br /> FIRST M, LAST PHONENUMeER <br /> BUaINEea NAME E-MAILAODR6aa <br /> Westlake Chemical Corporation <br /> OWNER HOMEADORESS <br /> CITY STATE ZIP <br /> Houston Texas 77056 <br /> OWNER MAILING ADOREss _ <br /> 2601 Post Oak BMd. <br /> MAITUNGADaREaig01TY STATS LP <br /> Houston Texas 77056 <br /> © <br /> CORPORATION <br /> 77 ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONsheLEPARV ❑OTHER <br /> SITE MITIGATION...ENVIRONMENTAL AssesSMENTQ VOLUNTARY CLEANUPO WATER QUALITY g HW PIPELINE INVESTIGATION O LOP g, <br /> 1'g0141TYIDlt'�•,� :�w l :�'r: .;:: OOOUjITID,.� 4M1,• �1l6G ED P OYEE�=- �LE4D41PE oy��ND. "WgOB Djao _FPA <br /> ` :'� .�•i`c•�!:.F�}-;{�Ay 7 ,,:i, I' _ fa � � �3,` �-e� ��iJ �n„��'��7y�t;'s3 4 —��,,�,^`r Y�h`>z <br /> FACILITY FILES COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHEENVIRONMEWALHEALTH DEPARTMENT? Yrs © No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,13UTANEWSOOPEOFWORK? Yes ❑ No 91 <br /> BUSINI!B&TAOIUV/SrTdPRaIEOTNAYE Westlake Chemical Corporation/CertalnTeed <br /> Srm AODREASIPRojEor LOCATION SuaE# BUSINESS PHONE <br /> 300 South Backman Road 209-365-2050 <br /> CITY STATE ZIP <br /> Lodi CA 05240 <br /> "'1,;.. :?..� ,:fir •�}•»" :j ii`-.�=-^!:;c;:c.. - <br /> 'egoFeupgavieoRAISTRIqT: LDOATppOptie,:. <br /> -.. '. <br /> MAILING ADDIIEBe,IF DIFFERENT FROM FAOIuTY ADDREa9 ATTENTtow oRCAke Or(OPTIONAL) <br /> 2801 Post Oak Blvd. <br /> MAILING ADDRESS OnV STATE ZIP <br /> Houslon TX 77046 <br /> „Z <br /> S`2�.,.e(S <br /> ..N <br /> A <br /> 5.� <br /> u� k> <br /> THIRD PARTY FRILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUIRNESSNAME ATTENTION.'OROARBOF(OPTlONAL) <br /> Saga Etwliannu bbl Consulting Jack A Wfnlla,P.D. <br /> MAILING ADDRESS PHONE <br /> 600 Chastain Fid.NW Ste 320 678-365.1340 <br /> Om STATE ZIP <br /> Kennesaw GA 30144 <br /> A000uNTADDREaeToSgNDFEES AND CHARGES: OWNER❑ FACILITY/131.113INES8E3 THIRD PARTYBILLINGI] <br /> )[InxiNO AND COAIDGTAKCE ACKNOWL®CAimi J.the undersigned Appllenot,certify that I nm ilia Omuer,Oporafor ANfhorizedAgenf,orResponsible Par6l and I aclmmvledge amt all PRRJJlr1;XA <br /> PG,wL7rTS,L•nPORCRNam'CfuROESand/or L7ouRLTCiuRcss nssodeted writh ads prof ectuill be bWtd tome at are address Identified above"IhoACCOU rAnnR=for Ods site. I also certify tbal all <br /> Information provided on this application is true Gad mrrectl and glint all regulated activities hill bo performed In nccardance,with all applicable SAN JOAQUW COUNTY ORDINANCE CODES mad/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.As the rmderslgned Ott-lien OpavAar,AaBiorltedAgenf,arRespaulbfe Pard for the project lacalcd above tm racWq/alto Addres+,I <br /> hereby authorize Uro release of any and ng results,reports,and other emironmenh+l assessment information to SAN JOAQUIN COUNTY IStrYRRONARE L HRAmn D TATE s on it is aIMURI le <br /> and at the some time It is provided tome or my■epmseatntIve. <br /> APPUOANTNAMH(PLEASEPRitIT) } Cti-�L i �n�C� SIGNATURE L" b7 <br /> Tae ` `L1L'CL_. v Aj <br /> CZ G1 <br /> APPROVED BY DATE AoaOUHnNO OFi'la!PRooraelNO OOMrIJ:iEn BY DATE <br /> 'BRE -0.�.N`•' •O' iP�Dc"'�'� `OATHOF PAYMENT PArMttNT T�P6� -REOEIPTN OHEOK f� �`� •�ZEpEyYR,D� ~Q. ;E,�tjj <br /> ILA: -- <br />