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SANOQUIN COUNTY ENVIRONMENTAL HEALTAARTMENT <br /> DATE 12/18/2012 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOMWERISCURRENTLYONFJL WITH EHD El <br /> PR(VERTYOWNat NAME Clifton Taylor (916)782 3330 <br /> FIRST M/ LAST PHONENUMBER <br /> BUSINESS NAME EMAIL ADDRESS <br /> Richland Crossroads L.P. ctaylor@richlandcommunities.com <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS <br /> 1508 Eureka Road Suite 140 <br /> MAILING ADOREBB CRY STATE ZIP <br /> Roseville CA 95661 <br /> ❑CORPORATION ❑INDIVIDUAL 0 PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP___ <br /> FACILITYID# INV# ACCOUNTID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENoy:ENO —RWCkCB_DTSC EPA_ <br /> JGHPPry <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> (STHISA NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑� <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> BUSINEWFACILITYISITEIPROJECTNAME City of Lathrop Crossroads WWTP <br /> SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> D'Arcy Parkway <br /> Cm STATE ZIP <br /> Lathrop,CA 95330 �^ <br /> BOARD OF SUPERVISOR DISTRICT \ LOCATION CODE V7 Kul KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS / ATTENTION:ORCARE OF fhPTIOAML) <br /> 390 Towne Centre Drive <br /> MAILING ADDRESS CITY STATE ZIP <br /> Lathrop,CA 95330 <br /> SICCOGE APN# COMMENT: <br /> f 130.32 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS PHONE <br /> CITY STATE ZIP <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER FACILITYIBUSINESS❑ THIRD PARTY BILLING[] <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the O.-nee,OperutaGAutboriZedAgeal,or Responsible Party and 1 acknowledge that all PERM/TFEES, <br /> PENALTJES,ENFORCEJOJNTCHARG£S and/or HDURLYCHARGES associated with this project will be billed to me at the address identified above as the ACCOUNPADDRERv for this Site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated acdvities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE COD"and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,AudioriZentAgeag or Roponrible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPUCANT NAME(PLEASE PRINT) Clifton Taylor SIGNATURE <br /> TITLE Vice President TAX ID# <br /> APPROVED BY DATE ACCOUMING OFFICE PROCESSING COMPI£fED BY DATE <br /> SITE MITIGATION AMOUHTPAIO DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORKPLANPE <br /> FEE:$ /x /q5 <br />