Laserfiche WebLink
SAN bbUIN COUNTY ENVIRONMENTAL HEALTH WARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 11/12/2015 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNE ESPONSIBLE PAR INFORMATION: CHECK IF OWNERS CURRENTLYON FILE w1TH EHD Q <br /> PROPERTY PHONE <br /> OWNER NAME FRST M, LAST (209) 662-5098 <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Richland Crossroads, L.P., a California limited partnership trevorsmith@richlandcommunities.com <br /> OWNER HOME ADDRESS 3000 Lava Ridge Court, Suite 115 ATTENTION:MCARE OF(OPTIONAL) Trevor Smith <br /> CITY Roseville, CA 95661 STATE ZIP <br /> OWNER MAILING ADDRESS 3000 Lava Ridge Court, Suite 115 <br /> MAILING ADDRESS CITY Roseville, CA 95661 STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL PARTNERSHIP [I GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- N RWQCB LEAD- E] DTSC LEAD ElFED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATERQUALITY(WDR) 2959 2954 <br /> 2950 2953 29601352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> Is THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO X <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES NO ❑ <br /> BUSINESSIFACILMISITEIPROJECTNAME City of Lathrop Crossroads Wastewater Treatment FacilityTA - 198-130-33 <br /> SITE ADDRESS I PROJECT LOCATKIN 18551 Christopher Way BUSINESS PHONE (209) 858-1645 <br /> CITY Lathrop, CA 95330 STATE ZIP <br /> BOARD OF SUPERVISOR DISTNICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 390 Towne Centre Drive <br /> MAILING ADDRESS CITY Lathrop, CA 95330 STATE zip <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:GROANS OF (OPTIONAL) <br /> MAILINGADORESS PHONE <br /> LIT? STATE zip <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERN FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,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 the ACCOUNTADDRESS 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 all results, reports, and other environmental assessment information to SAN JOAQUINN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my re �eyfor� _ <br /> APPLICANT NAME(PLEASE PRINT)Trevor Smith SIGNATURE <br /> P <br /> TITLE Manager, Central Valley TAXID# <br /> FA#: OWNER ID#: ACCOUNT#: ASSIGNED TO: <br /> ADO.. <br /> 3. l Ol l0o2135 ] A2o042-4�1l <br /> PRM: �2osyoSgg ACCOUNTING COMPLETED BY: //� DATE: q /i <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />