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San Joaquin County Environmental Health Department <br /> DATE11 10/1/2014 J MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> @SAgEp.ABfA4�RRHD IUP9NLY OWNER ID# CASE UNIT IV <br /> OWNER FILE:COMPLETEPROPERTYOWNER/RESPONSIBLE PARTY lwomAT/ON: CHECKY OWNER CVRREr aYONF&fW1rHEHDO <br /> PROPERTY OWNER NAME Stephen J Salvatore (209)941-7200 <br /> Feel I AU I Lasl PHONE NUMBER <br /> BUSINESS NAME City of Lathrop - Department of Public Works E-MAILADDRE99 webs _p @ p,ca.us <br /> ite wk cl lathrD <br /> Owner Home Address 390 Towne Centre Drive <br /> Clry STATEZIP <br /> Lathrop CA 95330 <br /> Owner Melling Address <br /> 390 Tovme Canino Drive <br /> Mailing Address City Slate Zip <br /> Lathrop CA 95330 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP Q GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_ VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID INV# ACCOUNT ID PR#1 RO# ASSIGNED EMPLOYEE LEAD AOENLY:EHD_RWQOS_DTSO_EPA_ <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT fNFORMAT/ON: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No X <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES No ❑ <br /> BUSINESSIFACILMISITEIPROJEOTNAME City of Lathrop Crossroads WWTP <br /> SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 18551 Christopher Way <br /> CITY STATE ZIP <br /> Lathrop,CA 95330 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CO DE KEV1 KEY2 <br /> Melling Addreas NCIFFERENT from Fee///ty Address Attention:or Care Of(opUanal) <br /> 390 Towne Centre Drive <br /> Mailing Adore.City STATE ZIP <br /> Lathrop.CA 95330 <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or-Responsible Party identified above. <br /> BUSINESS NAME HydroFocus, Inc. Attention:orCare Of (optional) <br /> Melling Address PHONE <br /> P.O.Box 2401 (530)759-2484 <br /> CITY STATE ZIP <br /> Davis.CA 95617 <br /> Ar o r•-dn Posy forfeea and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Q <br /> R I Yr' Y'I Cm sv Y AeEvnr Pnrsusr: I.the Imalmigmi Appliumt.cerlifY 0.1 I am the OJ Baer.Opemlor.Aathoriad AgaH,or Responsible Parry and I adomadedRe IML all PERurr Fla t. <br /> Pr_¢v.nls.F,',vFoerA'.ws-r Carer;e<nnsVar H K k1 rCU U,"'",eu,haM will,this pr jest will he billed Io meal the adores khadifol abore as the J, ,, .n':f onanes for this site. 1 Also"Mig thal nil <br /> information pmsidM on Bus uppliswtian 6 amc aM mrrsat:and Ilea all rel olauai aoieities will Iw imrfnmwd in ll.rdaace pith all npplieable Sin Jrl\QI16 Co,NnONirwnm Cod.andlnr <br /> Standards and Si.m.andbr Fwll.Kll.LAPS and Regulakom. As the undersigned never.Opemlor.Authari aul AgunL of Respamiblc Park'for Iiw pmjmt xKm1M alwve under facility/site addres.l <br /> hemhy aulhwrim the relnsc ofam'and all results-mpurh,and other environmenmlassessment information to SiV4 JOAQUIN <br /> "e m'nih151c vnd al the mmc lime it is prmidM to me IH mr rcpreseninlirc. COUNIONME IIFILlRI/TJaMEN[��as Ines <br /> e/Jars', <br /> it <br /> APPLICANT NAME(PLEASE PRINT)Stephen J.Salvatore SIGNATURE � � <br /> TAx ID# <br /> TITLE City Manager <br /> Ap mYad By Deb AccouMing OMCs Processing Completed By Dete <br /> SITE MITIGATION AMOUNT PAID ( DATE OF PAYMENT PAYMENT TYPE RECEIPT CHECK# <br /> RECEIVED BY WORK PLAN PE <br /> FFEE:$ <br />