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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE11 � '; ;"2j" MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> I --J ; v 20 2 <br /> SITE MITIGATION 8r LOP <br /> SHADED ASES--a END USE ONLY OWNER IDM CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNECLPRFO%psRrMCGRREWLroRF1Lc.,m EHDD <br /> PROPERTY OYm-RNAME Clifton Taylor (916)78'23330 <br /> Fmsr MI LAST PHONE NUMBER <br /> BUSINESSNANE E-MMLAoDRESS <br /> Richland Crossroads L.P. ctaylor(Prichlandcommunities.com <br /> OWNER HOME AOOCR'EEss I��o I? <br /> CITY <br /> p-0x l' I I I'Vo Lid./1 �r Yf/-+✓/11 l�Jyl may- _/11 ST I ZIP/t <br /> OWNER MAILING Moil V� <br /> 1508 Eureka Road Suite 140 <br /> MAILING ADDRESS CITYSTATE yp <br /> Roseville CA 95661 <br /> [:3 CORPORATION ❑INDIVIDUAL OPARTNERSHIP ❑GOVERNMENTAMNCY ElRESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY IDN INV# AOCOUNTID PROIROO ASSIGNED EMPLOYEE LEAD AGENCY:EHD�RWQCB_DISC_EPA_ <br /> /�= <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATIONS PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO IF <br /> IS THISAN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES IN No 0 <br /> BUSINESSIFACLRYISREIPROJECTNAME City of Lathrop Crossroads WWTP <br /> SITE ADDRESSIPROUECT LOCATION SUITE# BUSINESS PHONE <br /> D'Arcy Parkway <br /> Cm STATE Lp <br /> Lathrop,CA 95330 <br /> SOAROOF SUPMvlmoRDISTRICT LOCATION COO- KEY') KEYL <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILRYADORESS ATTENTIOW ORCARE OF(O IONAL) <br /> 390 Towne Centre Drive <br /> MAILINGADDRESSCTV STATE Zip <br /> Lathrop,CA 95330 <br /> SIC CODE APNIS 241_ow_b Cp ENT: <br /> THIRD PARTYBILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME ATTENTIOMORCARE OF(OpNOMTL) <br /> MAIUNGADORE;S PHONE <br /> CITY STATE LP <br /> ACCOUNTADDRESS To SEND FEES AND CHARGES: OWNERIN FACILITYIBUSINESSD THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the endetalgned Applleent,certify that I..the ONwer,Operemr,Authadood AgPN,or RaP nslM¢PMD,and 1 aelommlalee)hal ell PEIATT FEE$ <br /> PENALrrEY, and/or HDUSLTCIA n associated with this project will be billed m meat the address identified above ss the ACYT)W'rADDxrff for this site. I also oettily that all <br /> information provided on this oppiicadon a true and eorreO;and that all regulated activities will be performed In accordance with II app'eable JOAQmN COUNTY OROCMNAx CODES and/or <br /> STANDARD;and STATE and/or FEDERAL laws And REGULATIONS. As the undersigned OwResTQ Owner,Op"Ar,ARlh.'iWs or Respo bl a or the p IMI led above ander hcilityhlIsaddress,l <br /> hereby amborim the release of any and all results,reports,and other environmenml assessment Information to SAN JOAQUCI CO E. o. IVT t♦DEPARTNTENT as Soon as it is..liable <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PlE1SE PRINT) Clifton Taylor SIGNAILRE <br /> TITLE Vice President TMIDN <br /> APPROVED BY DATE ACCOUNTING ORIOE PROCESSING COMPLETED BY DATE <br /> SITE MIT IGATI N AMOUNT PAID GATE OF PAYMENT PgYMENT TYPE RECEIPT# CHECK# REGE1VEp BY WORK PIAX PE <br /> FEE:5 <br />