SITE INFORMATION AND CORRESPONDENCE FILE 1

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San oaquin County Environmental Health tepartment DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SITE MITIGATION &LOP SHADED AREASFOR EHD 11SFQNLY OWNER ID# CASE#'SP _"'8/5 UNIT IV OVMER FILE:COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CuRRENTL YON FILE WITH EHD PROPERTY OWNER NAME / 1 First MI Last PHONE NUMBER BUSINESS NAME Knife River Corporation E-MAIL ADDRESS Owner Home Address PO Box 6099 City Stockton- STATE Ca I. 95206 Owner Mailing Address PO Box 6099 Mailing Address City Stockton Smote Ca 7P 95206 CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ SITE MITIGATION._ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# -- INv# ]FACCOUNTID PR#IRO# � FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS I FACILITY/SITE INFORAwllom Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No j] Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES 2j No ❑ BUSINESS/FACILITY/SffENAME Knife River Corporation SITE ADDRESS 639 West Clay Steet SUITE# Bus]t§9L4sg 9501302 CITY Stockton STATECaZIP C95�j2�06 BOARD OF SUPERVISOR DISTRICT / LOCATION CODE KEv1 KEY2 Mailing Address dD1FFEREA?fromFac"/ Address Attention:orCare Of(optional)PO Box 60169 Mailing Address City Stockton STATE Ca ZIP 95205 SIC CODE 07 I -0 7 APN* COMMENT: ll ly - THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaclllty Operator identified above. BUSINESS NAME Advanced GeoEnvironmental, Inc. Attention:orCare Of (optional) Mailing Address 837 Shaw Road PHONE 209 467 10006 CITY Stockton STATE Ca zP 95215 AG92ugrAppaggs for fees and charges OWNER FACILITY/BUSINESS AHIRD PARTY BILLING BILLING AND COMPLIANCE ACKNowLEDGMENT: 1,the undersigned Applicant,certify that I am the avuer,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to meat the address identified above as the ACCOUNTADDRESS for this site. 1 also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordanee with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. t APPLICANT NAME(PLEASE PRINT) William Little SIGNATURE A �,,` TITLE Geologist TAxID# Approved By Date Accounfing Office Processing Completed By Data , p SITE MITIGATION AMOUNT PAID DATE_OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY !w FEE: