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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. CHEeKIF Oa1VERAYCuRREKTLYONFfLEwiTN EHO <br /> PROPERTY EJ Williams Property Mana ern T eA& MudrL — Vt Tec PNoNE 209-473-4022 <br /> OWNER NAME HRsr LASr <br /> BUSINESS NAME EJ Williams Property Management )G�-1/��""5 ` ��Ih 1Jr•.�> r�� :�-,E-w�IL ADDRESS <br /> OWNER HOME ADDRESS 802 West Weber Avenue I Z ATTENTION:ORCARE OF(apriaw) <br /> CITY Stockton,CA 95203 STATE ZJP <br /> OWNER MAILING ADDRESS PO BOX 7185,Stockton, CA 95203 <br /> MAllwc ADDRESS CRY STATE ZIP <br /> ❑COAPORATR)N ❑INDIVIDUAL ❑PAATN W-44tP ❑GOVERNMENT AGENCY ®REePONSIRLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ® RWQCB LEAD— ❑ RWQCB LEAD— <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD E]FED EPA LEAD <br /> 2950 2953 29601352613527 2955 2659 2954 <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 /> IS THIS AN EMSTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No ❑ <br /> BUSINESs(FACILRYISREMAOJECT NAME Tidewater Stockton(Chevron 206397211321 Request for Additional Methane and Sol Gas VOC Investigati it, <br /> AP . - 3 a Q(Jr1gS <br /> SrrrADDREss1PROJECtLocATION 802 West Weber Avenue SUNNE33P 109A73-4022 <br /> CITY Stockton,CA 95203 .STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE KEY1 KEY2 <br /> KkLMG ADDRESS,IF OIFFEREHT FROM FAW L rY ADDRESS <br /> NGaINGADoUessCrrY STATE LP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILUNG PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BustwEssNAw Stantec Consulting Services ATTENTION:cwCAREOF(owrow) <br /> MALiNGADOREss 3017 Kilgore Road,Suite 100 P"ONE 916$61-0400 <br /> CRY Rancho Cordova,CA 95670 STATE 75P <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[:] FACILITYIBUSINESS❑ THIRD PARTY BILUNG® <br /> BII LING 4ND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as theACCOUNTADDRESS for this site.1 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 FEDERAL 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 atl results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT US soon as it is available and at the same time it is provided to me or my representative— <br /> APPLICANT NAME(PLEASEPRWT) Tony Giglini SIGNATURE <br /> TITLE Associate Scientist TAuIDrj' -Q <br /> FA M: O WN6A ID l: ACCOUNT&. ASSIGNlED TO: <br /> fAD02.3Z3 �W�z�3SZ <br /> PRi:��(�� ACCOUNTING COMPLETED BY: DATE: 3 �� <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />