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Sari Joaquin County Environmental Health Department <br /> DATE 10/1/14 MASTER FILE RECORD INFORMATION "'MFR" GREEN FORIA <br /> _ SITE MIT/IIGATITION&LOP <br /> shiACEPa3 P_eatNplsf 9w OWNER ID/ — --.� CASE �irvi 1 IVRRA_ <br /> OWNER FILE:ComPLEr!SROPERTY OWNER/RESPONSIBLE PARIY/NFOamA7YON. CNIMVa OWNER CvaNEnnxroMraewITN END FB] <br /> PAEVERTY owMMMIT� Clifton Taylor P16j 782-3330 <br /> WS AR Leal PHoNSNumset <br /> BtsaNaEUNANE Richland Crossroads, L.P., a California limited partnership EiaAILADORC.ea — <br /> O"'e'"""'"°""3000 Lava Ridge Court, Suite 115 <br /> City ST."" <br /> Zlv <br /> !Roseville CA 956Fi1 <br /> Owner Melting Addrem, -- <br /> 3000 Lava Ridge Cori,SVile 115 <br /> Mailing Addrar qty Stele Zip <br /> Roseville CA 95661 <br /> ❑CORPostaTION ❑INDIVIDUAL ®PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY C1 OTHER <br /> SITE MmgATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> —_ <br /> FACILITY ID/ INVN AcaouNr ID PR/IRON ASSIGNED EMPLOYEE LEAD AGENCY,EXD_RWQCB_DTSC_EPA <br /> _ <br /> FACILITYFILE: COMPLETE BUSINESS/SITE/PROJECT/NFoRMAT/oil: <br /> Is this a NEW ProjectL.00ATIDN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NC IN <br /> Is this an EXISTING Project LOCATION but a New SCOPE OF WORN? YES ® No [ � <br /> SUMNE&sWA`N"YIS"PRa'E` Name:City of Lathrop Crossroads WWTP <br /> BnEAoIPEiSIPaOJECTLoannoN Bu11E/ BU RNESS PHONE <br /> 1501 D'Arcy Parkway <br /> Cm STATE LP <br /> Lathrop,CA 95330 <br /> BoN2D OF SUPERVISOR DISTRICT LOCAnoe Cuoa KEr1 KEY2 —� <br /> Mailing Addrean NOIFFERE1VrJha,,Fnnl//ryAddieee AtfelrUm:a,Ceres Of(gf/nnelf =__-- <br /> 390 Towne Centre Drive <br /> Mailing Addraee City STATE Zip ---- <br /> Latixop,CA 95.930 <br /> SIC CODE APNN CoarENi: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different iron Property Owner orResponsible Party identifledabove <br /> Sumess Name HydroFocus, Inc. Attention:orCTva Of(opframaq <br /> Address PHONE —� <br /> P.O..0,Bo Box 2401 (530)759-2484 <br /> CRY STATE Lp <br /> Davis,CA 95517 <br /> �gmaaAmM�s for feesand cherries OWNER FACILTYIBUSINESS THIRD PARTY BILLINGO <br /> BauHr.AND COMPLIANCT ACICNOWLEDGhtENT: 1.the undersigned Applicant,cerdfy that 1 am the 0.,or,vr-.nl v AatllariW Ager,or Rapomfble P,.yand I acknowledge that.r.PEserrr Ft <br /> PPJGLl1Ee,ENFOIa2ARlTC7e+sccs and.or/roourl'xrsoes aanariasN wiM this project will be billed m me et tM1e vddras itlentifNd above ss the ACY'DONTAnoRSSs for Nb alt. I also certify that nil <br /> Informvaou pmridel an this application is true and correeC and that all regulated•c ivitiea will be performed iR armrdanee 'ith all pliobN SV JOAptrN Cots. Ordinance Code and/or <br /> Standards and STATE and/or FendisAL Laws and Regulations. As the undersigned Owner,Operator,Auctioned Agent,car Rap helps for p looted above under f.e lity/site address,I <br /> Bereby authorise the release of Rnyandall results,reports,and other environmental ansosmnent information be SAN JOAQULN CO R F, AL HEALTH DEPARTMENT as soon as it <br /> is aYell.ble..d Rt the same lime it is provided to one or on,reprneentadYe. <br /> APPLICANT NAME(PLEASE Pswr) Ll � �(�� SIGNATURE -- <br /> TITLEy I�. Qt^ IID —�� ` Tm ID$ <br /> [AppraY.d ar onto � .:FaununO ORea rroeenshg eomplated By —770=W <br /> _����� <br /> $ITE MITtWTMN AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE� OCIPTN CHEGNN RECEIVED BY W'.PLAN PE <br /> FEE:4 _ �_a�_ <br />