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San J•Llin County Environmental Healthartment <br /> DATE 5/1/15 MASTER FILE RECORD INFORMATION"MW GREEN FORM <br /> �1 <br /> SITE MITIGATION & LOP <br /> SHADEGAREI1e FOREHDUSEONLY OWNER IDII010 0ozo' 2_0 CASE# UNIT IV <br /> OWNER FILE:COMPLETE-PROPER7YOWNER/RESPONSIBLE PARTY INFoi—nom cHECRtFDWNERCuRRIENnroRFILE wnHEHoEl <br /> PROPERTY OWNER NAME Contact: Mike Makerov BNSF Railway 909-386-4081 <br /> First MI Lest PHONE NUMBER <br /> BDBINESSNAME BNSF Railway E ILADDRESS <br /> Owner Homs Address <br /> City STATE LP <br /> Owner Mailing Address 740 East Carnegie Drive <br /> Mailing Address City San Bernadino Side Ca ap 92408-3571 <br /> X CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY X RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP—WATER QUALITY__HW PIPELINE INVESTIGATION LOP <br /> FAcILm ID# INv# Accouar lD PR#!RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWOCB,&_' DTSC_EPA_ <br /> rAWzZ kc2� fZD�} >°k fOflff tit noon" <br /> FACILITYFILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION., <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO X <br /> Is this an EAISTING Project LOCATION but a NEW SCOPE OF WORK? YES X No ❑ <br /> BUSINESSIFACILUNISITE/PROJECTNAME BNSF Railway Mormon Rail Yard <br /> SITE ADDRESS I PROJECT LOCATION 801 Diamond St. SuDE# BUSINESS PHONE <br /> 209-460-6336 <br /> Cm Stockton STATE Ca T'P 95205-7019 <br /> BOARGOFSUPERVIBOR DISTRICT LOCATION CODE Kvl KEY2 <br /> Mailing Address KC/FFERENTfrem Fw111tyAddress Attention:or Care Of(optiona9 <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identir/ed above. <br /> BUSINESS NAME Kennedy/Jenks Consultants. Inc. Attention:Decare Of (ophorra/J Mike McLeod <br /> Malling Address 303 Second St. Ste. 300 South PHONE 415-243-2150 <br /> cm San Francisco STATE Ca LP 94107 <br /> 9CCCHA? for fees and charges OWNER FACILRYIBUSINESS THIRD PARTY BILLING <br /> BILLING.AND COMPLIARcE ACKNOWLEDGMENT: I,the undersigned Applicant,certify,that I am the Owner,Operator,Authorized Agent,or Responsible Parry sad 1 aelmonledge that all PE&VITFEES, <br /> PEVALTIES,EYFORCEMErT CHARGES andlor HoO'In.v CxsxGES associated nith this project x111 be billed to me at the address identified above as the ACCOU\TADDRESS for this site. I also certify that all <br /> information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE eadh r FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorieed Agent,or Responsible Pa far the project located above under facility/site address,1 <br /> hereby sue and the release of any it and all restos,reports,and other environmental assessment information to SAN JOAQUIN CO�Y, IRONME HEALTHDEPARTMENT as soon as it <br /> is available and at the same time itis provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Mike McLeod SIGNATURE <br /> TITLE Geologist TAxID# <br /> Approved By Data Accounting Once Processing Completed By Dete <br /> SITE MITIGATION AMO PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: al 46 c <br />