SITE INFORMATION AND CORRESPONDENCE FILE 2

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SAN J*IN COUNTY ENVIRONMENTAL HEALTH D#RTMENT DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SITE MITIGATION & LOP SHADED AfflEAS FOR EHD ONLY OWNERIDX CASE{ G (j JO4 -7.3 51 UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER is CuRRENrc Y ON FREWITH EHD El PROPERTY OWNER NAME Sheldon Teranishi ( 20)9 835-3596 FIRST MI LAST PHONE NUMBER BUSINESS NAME N/A E-MAIL ADDRESS OWNER HOME ADDRESS 1600 Durham Ferry Road CITY Tracy STATE CA zip 95376 OWNER MAILING ADDRESS Same as above MAILING ADDRESS CITY ��yy STATE LP [-I CORPORATION 9�SNDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION K ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP FACILITYIDX INV# ACCOUNT IO PROIROO ASSIGNED EMPLOYEE LEAD AGENCY:END RWQCB_DTSC_EPA_ A030-50�-' 26 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No)t'� IS THIS AN EXISTING PROJECT LOCATION,BUT NEW SCOPE OF WORK? YES JDC No ❑ BUSINESSIFACILRYISrrFJPRWECTNAME Former George ' s Service SITE ADDRESS I PROJECT LOCATION 1600 Durham Ferry Road SUITE# BUSINESS PHONE CITY Tracy, STATE CAziP 95376 BOARD OF SUPERVISOR DISTRICT LocAT10N CODE KEPT KEYY MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) 1172 Kansas Avenue GZA, Authorized Agent MAILINGADDRESSCRY Modesto CA STATE ZIP 95351 SIC CODE APN# THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. SUSINESSNAME Ground Zero Analysis, Inc . ATTENTION:ORCAREOF (OPTIONALf ACotng Dept MAILING ADDRESS 1172 Kansas Avenue PHONE 209-522-4119 CITY Modesto, STATE CA zip 95351 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSO THIRD PARTY BILLINGOX BILLING AND COMPLIANCE ACKNOWLEDGNIEHT: I,the undersigned Applicant,certify that l am the Owner,Operator,Anrhori-ad Agent,or Responsible Party and I acknowledge that oto PERMIT PEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGFS associated with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will he performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and RECO WTIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Parry for the project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and other environmental assessment information to SAS JOAQUIN Co RUNNtENTAL HEALTH DEPAR\TMIENT m soon as it is available eIat the same time it u provided me or my representative. A APPLICANT NAME(PLEASE PRINT) Raynold Kablanow SIGNATURE TITLE Authorized Agent TAx ID# None APPROVEDBY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PMD DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORN PLAN PE FEE:; 356 1