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SANMAQUIN COUNTY ENVIRONMENTAL F'IEALTHTIEPARTMENT DATE05/09/2013 MASTER FILE RECORD INFORMATION "MFR" GREENFORM -- — ----- - — SITE MITIGATION & LOP $tJA_PEO ARFA6 FoRI<HD USE ONLY OWNER ID/ CASE R 5R 06 7 2 3Z S-- ZS-- UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNERS CVRRENM Y ON F/LE WrrH EH El PROPERTY OWNER NAME /2 0 9t 948-0302 FIRST Ml LAST PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS Knife River Corporation N/A OWNER HOME ADDRESS 639 West Clay Street Cm STATE ZIP Stockton CA 95206 OWNER MAILING ADDRESS PO BOX 6099 MAILING ADDRESS CITY STATE Zip Stockton CA 95206 ©CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT_—VOLUNTARY CLEANUP.--WATER QUALITY HW PIPELINE INVESTIGATION _LOP X FACILITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYE 1LEA7 NCY:EHDRWQCB_DTSC_EPA FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ BUSINESS/FACILITY/SITE/PROJECT NAME West Clay Properties SITE ADDRESS/PROJECT LOCATION 639 West Clay Street SUITE# BUSINESS PHONE CITY STATE ZIP Stockton CA 95206 FB--R..F SUPERVISOR DISTRICT LOCATION CODE KEY1 I KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS PO BOX 6099 ATTENTION:OR CARE OF(OPT)ONAL) MAILING ADDRESS CITY Stockton STATE zip CA 95206 SICCODE APN# COMMENT: L..E 21 THIRD PARTY BILLING INFO:COMPL E IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME advanced GeoEnvironment al Inc. ATTENTION:ORCARE OF llOPr/ONAL) William Little MAILING ADDRESS 837 Shaw Road PHONE 800-511-900 CITY Stockton STATE CA ZIP 680227 I ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER® FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ BILLING AND COMPLIANCE ACKNOW LEDC1IENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Part),and I acknowledge that all PERMITFEES, PENALTIES,F_NFORCEMENTCHARCEs and/or HOURLYCHARGES associated with this project Will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODes and/or STANDARDS and STATE and/or FEDERAL Laws and RBGULATTONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Para,for the project located above under facility/site address,I hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) William Little SIGNATURE /'o TITLE Geologist - Agent of owner TAX ID# APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMEttT TYPE RECEIPT# CHECK# RECEIVED BY �WORKLAN PE FEE:$ — QO.!;--