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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 07/20/17 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PAR TY INFORMATION: CHECKIr OWNER/4F CURRENFIICWFILE WTWEHD® <br /> PROPERTY A ST PHONE 925-674-8400 <br /> 1, 1 <br /> BUSINESS NAME East Louise Business Park E- ILADDRESE <br /> OWNER HOME ADDRESS 1200 Concord Avenue, Suite 200 <br /> CITY Concord, CA STATE LP 94520 <br /> OWNER MAILING ADDRESS 1200 Concord Avenue, Suite 200 <br /> MAIUiNNo AOORESSCnr STATE zip 94520 <br /> qJ CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGEMCY ❑RESPONSISLEPARTY ❑OTIIER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCBLEAD— XJ RWQCBLEAo— <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALrn-; ) [I DTSC LEAD ❑FED EPA LEAD <br /> 2950 2953 29601352613527 2965 2959 2954 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: µµ <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No pI <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORN? YES NO ❑ <br /> BUSINESSIFACILNYISRFJPROIECTNAME East Louise Business Park APN: 198-120-09 <br /> SIrEADCRESSIPROIECTLODATION 500 East Louise Avenue, Lathrop, Ca 95330 BUSINEESPHONE 925-674-8400 <br /> CRY STATE zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCOOE NEVI KEYL <br /> MAILING ADDRESS,IF DIFFERENT FROM FACIIITY ADDRESS 1200 Concord Avenue, Suite 200 ATTENTIOWORCAREOF(OPTIOML) <br /> MAILINGADDRESSCITY Concord, CA STATE 21P 94520 <br /> SIC CODE 11 COMMENT: <br /> THIRD PARTY BILUNG INFO:COMPLETE IF BILLING PARTY IS DIFFERENTFROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME East Louise Business Park ATTENTION:ORCARE OF 10PnONAV <br /> MAILING ADDRESS 1200 Concord Avenue,Suite 200 PHONE 925-674-8400 <br /> CITY Concord, CA � STATE ZIP 94520 <br /> AIX:OUNTAODRESSTOSENDFEESANOCHARGES: OWNERK FACILnY1BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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.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 <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 JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRIM) Dana Parry SIGNATURE /J <br /> A a.Nti,`lra4.� <br /> TITLE PJ WWW p� T"IDS 94-1674460 <br /> FA oo <br /> FA 9: � — 7 OWNERLDA:0Ary) ACCOUNTS: ASSIGNED TO: <br /> .GMYNNI <br /> L./ <br /> R }-Y ACCOUNTS:tJINVOICES: <br /> ACCOUNTING@FIOE PROCESSING COMPLETED BY: DATE: <br /> 5-7-2015 <br /> Site Mitigation MFR 29- <br />