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SAN JO IN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> SITE MITISION MASTER FILE RECORD INFATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 08/01/20117 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKxOWHERisCuaRE,vrcro*RLEwTHEND <br /> � <br /> PROPERTY RB Louise LLC Et.Al. PH 1!925-674-8400 <br /> OWNER NAME FIRST MI LAST <br /> BUSINESS NAME EAST LOUISE BUSINESS PARK EMAILADDRESS <br /> OWNERHOIIEADDRESS 1200 CONCORD AVENUE,SUITE 200 ATTENTION:ORCARE OF(OGr/OHAt) DANA PARRY <br /> Cm CONCORD, CA STATE ZIP 94520 <br /> OWNER MAILING ADDRESS,SAME <br /> MMUNGADDRESSCUY SAME STATE LP <br /> E CORPORATION ❑INONIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTNER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ® RWQCB LEAD- ❑ DTSC LEAD [I FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION VIATERQUALITY(WD R) 2959 2954 <br /> 2950 2953 2960/352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN DUSTING PROJECT LOCATION,BUT ANEW SCOPE OFWORK? YES ® NO ❑ <br /> BUBINEsWFACILUY1SOE1PROJEw NAME EAST LOUISE BUSINESS PARK APN:198-1204=9 <br /> SUE AGGRESS/PROJECT LOCATION 500 EAST LOUISE AND 17100 MURPHHY PARKWAY BUSINESS PHONE:9'25-674-8400 <br /> CITY LATHROP STATE CA ZJP95330 <br /> BOARDOFSUPERWSORDISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILRY ADDRESS <br /> MAIUNGADDRESSCI Y STATE ZJP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME EAST LOUISE BUSINESS PARK ATTENTION:ORCARE OF(OPT/OHAo <br /> MAILINGAGDRESS 1200 CONCORD AVENUE,SUITE 200 PHONE 925-674-8400 <br /> Cm CONCORD,CA STATE 7JP95330 <br /> ACCOUNTADDREss TO SEND FEESAND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or <br /> Responsible Pally and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br /> this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I 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 Owner, <br /> Operator,Authorized Agent,or Responsible Parry for the project located above under facility/site address,I hereby authorize the release of <br /> any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my repres/entartit�i1v,t, -nD. <br /> APPLICANT NAME(PLEASE PRINT) WILLIAM LITTLE SIGNATURE <br /> TRUEAGENT-GEOLOGIST TAZID# <br /> FA M. OWNER ID#: ACCOUNT#: ASSIGNED TO: <br /> PR#' ACCOUNTING COMPLETED BY: DATE: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> 2903 523 $456.00 1 �� <br /> Work Plan 2g04 523 $760.00 4 23n`tl ' x �S�3 ) I'I S (�>7"180U� <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />