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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE ��jj MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> -Y`-_13 SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHO USE ONLYTRaob1, a UNIT IV <br /> OWNER IDN LASER 304667 <br /> 1 1 <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: QNECRlFOWNERlB CURREMWf <br /> LYONFRETN END El <br /> PROPERTYOWNERNAME Clifton I I Taylor (916)7823330 <br /> Fess? MI LAST PHONE NUMBER <br /> BusuiesBNAME E-AwLAOOHEe9 <br /> Richland Crossroads LP. ctayloriVrichlandcommunities.com <br /> OWNERHjom AYDOyR'EESS IITO9 eb yeL"— � �f �. yn/' <br /> Cm P-09-9 I lc' r{'JV�r G`I 41 STC. C1 <br /> OWNERMAILINGAOdiEBs <br /> 1508 Eureka Road Suite 140 <br /> MMLJNo AmmESSCm STATE Lp <br /> ROsevllle CA 9.9 <br /> [IconscatATION ❑INDIVIDUAL QPARTNERSHIP ❑GGVERNMENTAGENCY ❑RESPONSIBLE PARTY LI OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_V!= <br /> CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITYID# INV* ACCCUNTIO Pq OU ASSIGNEDEMPLOYEE LEAOAGIVIM:FJIO,�RWQCS_DTSC_EPA_ <br /> 7- Vz'1 '7M 2Q-761-3 I /G4 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THMA NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTIiE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO 9 <br /> ISTHIS AN EKIBTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES IB No ❑ <br /> BUSINEBS/FACILRYISREIPROJECT NAME City of Lathrop Crossroads WWTP <br /> SITEAUMIRRIPRO.IECTLOCATION Sun Ile Bumes8PHIXJE <br /> D'Arcy Parkway /s-o/ L ARG`( Q/G 0 <br /> CRY STATE Zip <br /> Lathrop,CA 95330 <br /> BOARD OF SOPERVISpt DISTRICT LoCATIoN CODE 7 Kul KEY2 <br /> MAIUNGADOREBS,IF DIFFERENT FROM FACIUII'AODRES9 ATTENTION:ORCARE OF(OPTIONAL) <br /> 390 Towne Centre Drive <br /> MARJNGAOCREss COY STATE LP <br /> Lathrop,CA 95330 <br /> SIC COOE APNM COMMENT: <br /> 241-o�_a <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUeINE89 Maine ATTEMION:ORCARE OF(GPTIONAL) <br /> MAILING MESS PHONE <br /> Crry STATE zJP <br /> ACCOUNT ADDRE83 TO BEND FEES AND CHARGES! OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn.uNG AND COWLiANCE Aflm] .EDGMENT: 19 the undersigned Appllcant,certify that I am the Owner,Opcmor,AurhonmAAgad,INResponslble Porry and I acknowledge thalati PRRmrFoEs, <br /> PENALTIF_t,F.NTORC8M8NTClMRCFs vnd/or JJOUMrCr aiEf'assuclaled with this project will be billed in meat the address identified above u the Alemurnr"REE;for this site.Lahoeemifythat.11 <br /> information provided on this application is true and correct sod that all regulated activities will be performed In accardmee wlth U app cable SAJI JOAQUIN COUNTY ORDINANCE COMS and/or <br /> STAnOMD3and STATE.and/or FEDERAL Laws and RECD TIONS. AS the undersigned Ownep DANSIog AuOprRAdAgm4 or Resp / orthep jcrtl ted above under facilityhileaddress,l <br /> hereby autborlee the release of any and all results,reports,and other environmental assessment Information to SAN JOAQImt CD E tetrr 'DEPABIDeN'T ar soon AS it is available <br /> and at the me tree it is provided to me or{mn <br /> �y repre mutdv <br /> APPLICANTNAME(PLEASEPmNIl Clifton Taylor BIGNANRE <br /> TME Vice President TAKIDN <br /> APPROVED Bf DATE ACCOUNPNG OFFICE PROCESSNO CONP1ETSE BY WTE S <br /> SITEMITIGATI N AMOUNT PAID DATE OF PAYNENT PAYMENTTPE RECEIPTII CHECKS RECEIVED BY WORKPLANPE <br /> FEE: <br />