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<br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT
<br /> DATE -FILE RECORD INFORMATION"MFR" - GREEN FORM
<br /> 5-3-2013 SITE MITIGATION&LOP
<br /> �(y•,_�._:T _fit,:. 3 UNIT IV
<br /> PHAamAAUer011EHDUMONLY .OWNEk�DIF,='4`� �'`�.•; 'r`�I:�K: i• •OAeei !t.,44YF, �.'';'t?- ^
<br /> OWNER PI&K COMPLETE PROPERTY OWNERIRESPONeWLE PARTY INFORMATION: ONEaN/FOWNERNODRwonroNfI mim EHD
<br /> PROPrMYOWNIRNAme Westlake Chamlcai Corporation 718 69Q-9111
<br /> RRsr All LAST pHONENUMpER
<br /> SU6INEES NAME EMAILADORiti
<br /> Westlake Chemical Corporation
<br /> OWNER Homr ADOREsa
<br /> CITY STATE LP
<br /> Houston Texas 770b6
<br /> OWNER WuNG ADOREes
<br /> 2801 Post Oak DIVd.
<br /> MAtuNGADDREasOrrY a are ZIP
<br /> Houston Texas 77056
<br /> 9OORPORATIIO-N7 ❑INDIVIDUAL ❑PARTNERSHIP [I GOVERNMENT AOENOY ❑ RTY RE8PONSI6LEPAOTHER
<br /> SITE
<br /> SITE MITIGATION.t�- ENVIRONMENTAL ASsessMENTO VOLUNTARY CLEANUPS WATER QUALITY CA HW PIPELINE INVESTIGATION LOP [A
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<br /> PACILITI(FILEI COMPLETE BUSINESS/SITEI PROIlE0T1NFARMATION:
<br /> Is THIS A NEW pRoJEoTL.GGATlON NC.IT PR61OUSLY REGULATED SY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES (] No❑
<br /> ISTHISANEKISTINGPROJECT WCATIONtBUT ANEW SCOPE OrWORK? YE6 D No w
<br /> BU.simas FAouvismdPaoJzOTNAMe Westlake Chemical Corporation!CertainTeed
<br /> erreADDRE112 PROJI-Lo0ATi0N Duni>x 911tINi66PHONE
<br /> 300;6outh pe an Road 209 365-2050
<br /> Cm STATE Zip
<br /> CA 95240
<br /> Lgdi �
<br /> • - :;:.L:+_ ,`r�,.k 4'I,.:::•:�i-?1'4y: •�.ti^.:-'. :;S,v�:�_p.• 't:.�[.,..
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<br /> p oPeDPttRVteoRP.tsTRrQT�' LoDAT.•N..,..4eia:: _.in., �•:_'.,z=',� �,.c3':-._�_�:
<br /> MAILING Aonuse o IF DIFFERENr FROM FAOILrTY ADDRies ATTENTION:OROAtIGOP(OPRONAL)
<br /> 2801 Post Oak Blvd.'
<br /> STATE LP
<br /> IRAILINe ADORE86OrlY TX 77046
<br /> Houston - :r fa,l'i.: :,::;=tisk:; •,
<br /> "�t4 i ,'; ,},5xi
<br /> S.t•,
<br /> 0
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<br /> THIRD.PARTY BILLING INFO:COMPLETE IF BILLING PARWO blFFER.%TFROM PROPERTY OW$0R0R R98PONSWLE PARTY ID.ENTlFIED ABOVE.
<br /> SU61NESiNAMe JAeakAWInUe ns ON
<br /> O ReCP(oPnaNAti)
<br /> sage Enyirowental Canstdling
<br /> PNONe
<br /> WAaLtHe ADDIIEes AWLIAR5.1340.
<br /> 6QQ Ghasteln Rd.NW Ste 320
<br /> STATE LP
<br /> CITY GA 30144
<br /> Kennesaw
<br /> [A:-�PNTADDREes1?DiENDPEEiANDOHARGEbi OWNERD FACILITYIBUSINESSD THIRD PARTYBILLINGO
<br /> cn.,.,n.....n rrAKrE ACI(NOtYi.EOOAtENrt I,lite undenlgDtd Appllewt,cerllar(lint I noir AID Coiter,Oprrato,ArrthaifaerlAAxnt,orR�RrlblsPnrQ and I Aelmmr[edie ihnt nD PdltaltTF1'as,
<br /> Al,W.lerrlffr olrcaAMfff,OmRctisaadlor HounrCrrARcss nssactnkd Tstth titin prciccttri9 be bWea to me nt lite address identlfied above of 1hoAcrnuA7APDRsss for dets die.I also certify tbaf all
<br /> Ot DtxANCB CoOes and/or
<br /> InforMA1ID11 proeidetln Cthts applleadon is Iron and correct,And thaton Squinted netnides hill be perfaratcd In accordnneo%A lh pTl nppUeable SAR JOAQtnN COUNTY
<br /> STANDAM and STATE and/or FEDERALLnt%s and REGULATIONS.As the tmderdEned Ohne,Operator,AudrorlteAAgertl,orRerponsIble Pa*Car The project located above un facility/srto address,I
<br /> ltemby nuthorke Me release orany and aU reSulls,reports,and other emironmerhA osstssment farormndon to SANJOAQUIN COUNV UNMONWNIAL 1IEALTRD T,.E S on itis nvninhle
<br /> and of the Same time It Is provided to me army represeatnth•e. p
<br /> APPLIoANTNAME(PLEASE PRINT) ` n— SIGNATURE
<br /> TatID# b.2✓U
<br /> 41
<br /> TTrLE `�-- Ul
<br /> APPROVEO RY DATE AD60UHrINO QRIOe PAooEseMp OOMrtet'rD eY DATE
<br /> �61TE Ij10 TI '•11-bO;l�♦NjT,PAIu'' ''DATEOF PAYM6HY PAo(MINT T�It;II ' REOeIPTk CHeOK :;L,� ��EQ.EIYfiR`D SY _QR>S 4i
<br /> ELEIrT'
<br /> `i ,: J•� .rpt"'_
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