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SAN JOA, .J COUNTY ENVIRONMENTAL HEALTH DEPA ENT <br /> DATE 1/15/2013 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> 200l��� <br /> ``HARED AREAS FOR EHD USE ONLY OWNER IDK CASE Y (' UNIT 1V <br /> ' <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OWNERS CURRENTL Y ON FILE WITH EHD <br /> PROPERTY OWNER NAME John B. Anderson ( ) <br /> FIRST MI LAST PHONE Nt1MBER <br /> BUSINESS NAME EMAIL AwRE$s <br /> Anderson Farms <br /> OWNER HOME ADDRESS <br /> _ 4600 Fermi Place <br /> CITY <br /> Davis $CA ZTE IP 95616 <br /> OWNER MAILING ADDRESS P. O. Box 1410 <br /> MAILING ADDRESS CITY STATE ZP <br /> Davis CA 95617 <br /> ❑CORPORATION X INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP - WATER QUALITY HW PIPELINE INVESTIGATION --LOP <br /> _ <br /> FACILITY ID YINVM ACCOUNT ID PR I!ROY ABSIGNED EMPLOYEE LEADAGENGY:EHD_RWQCB L DTSC_EPA <br /> ovo52? r�e�5�3� PeoS358Sc� I -loHtvuy <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: �A <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Id <br /> IS THIS AN EMSTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES NO ❑ <br /> BUSINESS/FACILITYfSITEIPROJECTNAME A. W. Hays Facility <br /> I—E ADDRESS I PROJECT LOCATION 2005 Navy Drive SUITE BUSINESS PHONE <br /> ylry Stockton STATE ZIP <br /> CA <br /> BOARD OF SUPERVISOR DISTRICT I LOCATION CODE KEY1 K�•2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN I COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Pheasant Investment Corporation ATTENTION:ORCARE OF (OPrIONAL) <br /> MAILING ADDRESS 611 North Street PHONE (530) 666-2185 <br /> CITY STATE ZIP <br /> Woodland CA 95695 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[:] FAC ILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLANI,:d.YD C ONIPIA XNCE.\CAVON'I.F.M:\li:\T: 1,the unlcrsigned Lpplicant,certify that I ant the Onner,I/prrntnr,.luthorizol-Ig,.nt.nr N.epnnsihle Parn'and I mknosrledg,that all PFRa117'I'FFS, <br /> PFnfit.IIF.S,rNFORI'L:.IIL:.V1 CI!,Rhes and/or 11ovRL 1"C 111R<;Ft av50e1J tell WIlh this p,.jP t N'III he billed IO me:I[the address idenlllled abode as the.accof'\T.IIIPRF.LS for this site. I also certlR that all <br /> Inflld'll lat"In in-i h•II—this Application is title altd enrrcaanti that:Ill regulated adnitirs nil!!n•performed ill aeenl,lane.•%lid)all:lpplieahle tine.)0%QIIIN C()i"YT\()HDIN.cn('r.C oI)FS and/or <br /> ST VNI)ARDS and S'I A 1 E aml/OIFEDERnI.Lints anti RECULAI I(mS. :T5 the undersigned OHner,OperRmr,,luthoriuel.!gent,ur Reap—ihle Pulte f Ir lite prugeda)oialedi alpne under r;wIitclsilr addn•ss,I <br /> hereby autlwrizc the rriracr ul'any anti all resulLs,reports,and other etvirwtmenl:nl assl.•ssntent information lO SAN.Ill W(IN('01N 11 E\s IRONMIENTAL I 61A %111 r as soon as it is aT aihable <br /> and at the same linle it h provided lu my of my representati.e. <br /> APPLICANT NAME(PLEASE PRINT) Kent N. Calfee SIGNATURE <br /> TITLE President. Pheasant Investment Corporation TAX IDI 68-034170 <br /> IOVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITK)ATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT I CHECK I RECEIVED BY WORK PLAN PE <br /> FEE: Zgs7 <br />