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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE11 12/18/2012 MASTER FILE RECORD INFORMATION`pMFR" GREEN FORM <br /> ��y / z 9SITE MITIGATION&LOP <br /> SHAVED AREAS FOR ENO use ONLY OWNER 100 DW t�l {—TC� CAW# 5"CLLC UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE VV PARTY INFORMATION: CREcReoasmaR Is exaneS IrOWFILEMI,EHD� <br /> PROPERTYOWNERNAME Clifton Taylor (916)782 3330 <br /> Fear MI LAST PHONENUMBER <br /> BUSINESSNAME EiA1ILADDRESB <br /> Richland Crossroads L.P. Ctaylor@richiandcommunities.com <br /> OWNERrHOMEAI <br /> WAirrms I�O �i / _, •��� J ^ 1 n- �O /� <br /> CITY1 <br /> OM/mn JI Imo (— <br /> CGVIv G' LVJ1�` Sr ci zaoq <br /> OWNER MAILINGADDRESS <br /> 1508 Eureka Road Suite 140 <br /> MMLINGAODRE89 CRY STALE ZJF95 <br /> Roseville CA 661 <br /> ❑CORPOaanON ❑INDIVIDUAL QPARTNERSHIP j]GOVERNMENTAGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILMIDN INV# ACCOUNT ID I P ROM ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA <br /> 0211.E 1_ _ 341 $`] OS3J.F <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOTPREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No O <br /> ISTHISAN EXISTING PROJECT LOCATION,BUTA NEW SCOPE OF WORK? YES No ❑ <br /> SUSINESSIFACA.m'ISREIPRGJECT NAME City of Lathrop Crossroads WWTP <br /> SITE AOasess I PROJECT LDDATON SUITE# BUSINESS PHONE <br /> D'Arcy Parkway <br /> CITY STATE LP <br /> Lathrop,CA 95330 <br /> BOAROOFSUPERVISOR DISTRICT LOCATION CODE Kul KEY2 <br /> MAILINGADDREBB,IF DIFFERENT mom FAmLRYADDRESS ATriarrao :ORCAREOF(OPOOMAL) <br /> 390 Towne Centre Drive <br /> MAILINGAOGRESSCITY STATE ZIP <br /> Lathrop,CA 95MO <br /> SICCODE AM01 COMMExr: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINEea NAME ATTENTION:ORCARE OF(GFTIORAL) <br /> MAILINOADORE IS PHONE <br /> Cm STATE LP <br /> ACCOUNTADDREBS TO SEND FEES AND CHARGES: OWNER. FACILRYIBUSINESSD THIRD PARTY BILLING. <br /> BMUNG AND COMPLIANCE ACKNOM.EDGMEW: 1,the undersiym am the Owner,Operarer,ARYhorfuGAgaN,or Reeponitbk Party and lochnowledge thalan PFxsm'FEFs, <br /> PENALIIRY,ENFORCEVENTOTdRORY and/or f0VnYCRAR6FS associated with this project will be billed te me at the address identified shaven NeA=vYTADARs&Star this site lalso certify tM1at di <br /> information provided on this application tt true and rorraN and that all regulated activities will be performed In anodmce wiN a Bpp'rable JOAQUuf COUNTY GAl11KANCE CODES and/or <br /> STAnvARDSand STATE and/or FEDERAL Lomond REGuLAnONs. Aa the undersiBlld Owner,Operaror,Au@ara<tlggeA(,orR bl a or the is jectl tedabovemderfnililyhiteaddrssa,l <br /> hereby authorize the mime of any and all results,reports,and other envGoementol Assessment Information to SAN JOAQUw CO E RO ffiW DEPAttra Em'as soon a It is available <br /> andatthesametimeitisp...idd to meet may repres ti,. <br /> APPIICAm NAME(PUBASEPRINT) Clifton Taylor BIGNATIIRE <br /> TmE Vice President TMID# <br /> APPROV60BY DATE ACCOUNT..OFr1OEPRDCESSINO CONPlElE08Y WTE I]' �'� I Zi <br /> SITE MITI TON I AMOUNTPAID DATEOFPAYMENT PAYMENTIYPE RECEIPTS CHECK# RECEIVED BY WOR pPLANPE <br /> FEE:III __ <br />