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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 12/1/15 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: C/IeoKIrOmyrRIsCNmRERrLYoNr/LE wrT/I EHD <br /> PROPERTY EJ Williams Property Mana ement PHONE 209A13-4022 <br /> OWNER NAME k "IRST I M1 LAST <br /> BUSINESS NAME EJ Williams Property Management E-MAIL ADoREas <br /> OWNER HOME ADDRESS 802 West Weber Avenue ATTENTION:ORCARE OF(OPTIONAL) <br /> Cm Stockton,CA 95203 STATE bp <br /> OWNER MAILING ADDRESS PO BOX 7185,Stockton,CA 95203 <br /> MAILING ADDRESS CrrY STATE ZIP <br /> ❑CorawRAT1ON ❑INDNNDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPONSIBLE PAR" ❑OTNER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ® RWQCB LEAD— ❑ RWQCB LEAD— <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD [:]FED EPA LEAD <br /> 2959 2964 <br /> 2950 2953 296013526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THLS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? yes ❑ No ❑ <br /> 13 THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINEss1FAC11.ITY/SI1rEIPROJECT NAME Tidewater Stockton(Chevron 208397/211321 Request Tor Additional MoUhane and SOY Gas VOC Invee4gati n ApN. 1 <br /> - 3 O ( QrA y <br /> (j nl `I <br /> SITE ADORESS t PROJECT LocA1 io N 802 West Weber Avenue SUSINE53P <br /> `M9-473-4022 <br /> CI'Y Stockton,CA 95203 STATE LP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FAGUTY ADDRFas <br /> MAKING ADDREas CrrY STATE LP <br /> BIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAMC Stantec Consulting Services ATTEHTION:ORCAM OF (OPYW UL) <br /> MALINGADowas 3017 Kilgore Road,Suite 100 - PHONE 916-861-0400 <br /> CITY Rancho Cordova,CA 95670 STATE ZIP <br /> FOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[-) FACwTYBUSINESS❑ THIRD PARTY Bit LINGI?9 <br /> BILLING Arm COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent, <br /> or Responsible Party and 1 acknowledge that all PERMIT FEES,PL•NALYwv, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACC'OUNTADDRESs ror this si(e. I also certify that all information <br /> provided on this application is true and correct, and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE: and/or FFDF,RAI. Laws and REGULATIONS. As the undersigned <br /> Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQl1IN COUNT), ENVIRONMENTAL <br /> HEALTI1 DHPARTMEN7 as soon as it is available and at the same time it is provided to me or my rrepresentative. <br /> APPLICANTNAME(PLEASEPRwr) TonyGiglini SIGNATURE <br /> 001 <br /> f <br /> TITLE Associate Scientist TAX 10# ALt 0 <br /> FA is OWNGR ID l: ACCOUNT>k ASSIGNED TO: <br /> PRT- ACCOUNTING COMPLETED BY: DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />