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� , 4 <br /> SAN JoacIUIN COUNTY ENVIRONMENTAL HEALTH 1PARTMENT <br /> DATE 03/06/13 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> - rVon $ SITE MITIGATION&LOP <br /> S O ND OWNER IDA DW OoS7Z CASE# S2WGLY9G <br /> UNIT IV <br /> COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: - CHEOHlFow-VERls OURRENTLTONF/LEW/TH ENO <br /> El <br /> PROPERTY OWNER NAME Katy Laubach ( ) . (408) 912-2287 <br /> FIRST Ml LAST PHONE NUMBER <br /> BUSINESS NAME Wildcat Metals-Carnegie LLC E-MAIL ADDRESS <br /> OWNERHOMEADDRESS 890 Faulstich Court <br /> CITY San Jose, CA <br /> STATE CA nP 95112 <br /> OWNERMAIUNGADDM11 <br /> MAILING ADDRESB CRY <br /> STATE ZIP <br /> flPOliAT10N ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY <br /> ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNTID O# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC XX EPA <br /> G94Z q 9 /7 I�sbs7i3 l�w AA�y — <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? <br /> YES No E]BU91NE83/FACILRY/SITFIPRWECT NAME Commercial Property - monitoring well destructions <br /> SITEADDRESSIPROJECTLOCATION 555 Carnegie Way <br /> SURE# BUSINESS PHONE <br /> Cm 408-912-2287 <br /> Manteca ' I STATECA ZIP 953375 <br /> BOARD OF SUPERVISOR DISTRICT S LOCATION CODE '-F KEY1 KEY2 <br /> MAWNG ADDRESS,IF DIFFERENT FROM FACILITY ADDRE88 1 <br /> ATTENTION:OR CARE OF(OPTIONAL/ <br /> MAILING ADOREGB CITY <br /> STATE ZIP <br /> SIC CODE APN#1flF.I-, Q-6 1 I <br /> COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUBINESS NAME Advanced Geo Environmental Inc. ATTENTION:ORCARE OF(OPWML) <br /> MAIUNOADDRESS 837 Shaw Road <br /> PRONE 209-467-1006 <br /> Cm Stockton <br /> STATE CA ZIP 95215 <br /> AGDGUNTAomm TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLIN <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT, 1,the undersigned Applicant,certify lhatlam the Owuer,OPemtaq Autborfzed Agent or Responsible Party and l acknowledge thatall P£RM?FEa, <br /> PENALTI£e,ENFORCEMENTCIIARGES and/or HOURLYCHARGES associated with this project will be billed tame at the address identified above as the ACCOUNTADOR£SS for this site. 1 also certify Nett all <br /> information provided on this application is true and correct;and that all regulated acfivifirs will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDAM and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,AuchorieedAgent or Responsible Party for the project located above under facility/sile address,1 <br /> hereby authorize the release ofany and all results,repores,and other environmental assessment information N SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided M me or my NT representative <br /> APPLICANAME(PLEASE PRINT) William Little SIGNATURE <br /> TITLE Geologist TAXID# ���'���CCC ✓j YCACXXX <br /> APPROVED BY DATE AOGOU"No OiRcEPRO0E,MINOCOMPIETEDBY <br /> DATE <br /> LEE <br /> ITE MITIGATION AMOUNT PAID DATEOFPAYpENT PAYMENTTYPE RECEIPT# <br /> FEE:; '63-7S-- 3fes.//. i CNECK/ RECEIVE'BYe WOBN?ci-oPE <br /> f/VXl//1 1/ 3(.(.-7'7 �' �fi� G/r i S <br />