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1 <br /> SAN.JOAUUIN COUNTY ENVIRONMENTAL HEALTH DEI-ARTMEIVT RECEIVED <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM JUN 2 5 2018 <br /> DATE <br /> 10119/2017 E/YI/llll),___AALREAS FOR END USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF0WHER1SCURRENrLY L wirH EHD <br /> PROPERTY PHONE <br /> OWNER NAME I FIRST I M/ I LAST <br /> BUSINEssNAME SAN JOAQUIN LUMBER COMPANY,ACALIFORNIACORPORATION E4MLADDRESe JOE EUPHRAT@YAHOO.COM <br /> OWNER HOME ADDRESS ATTENTION:OR CARE OF IOPnONALJ <br /> CITY STATE ZJP <br /> OWNER MAILING ADDRESS 901 BUTTERFIELDROAO <br /> MAIUNG ADDRESS CRY San Anselmo STATE CA LP 94960 <br /> ❑CORPORATION X INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> 15 THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No El <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No IA <br /> BUSINESS/FACILITY/SRE/PROJECT NAME APN: <br /> SITE ADDRESS/PROJECT LOCATION 455 EAST ELEVENTH STREET BUSINESS PHONE <br /> CITY TRACY STATE LP 95201 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAIUNG ADDRESS CITY STATE zip <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Terraphase Engineering ATTENTION:ORCARE OF(OPrlONAL) <br /> MAIUNGADDRESS 1404 Franklin St#600 PHONE510 645 1850 X1 UZ <br /> CITY Oakland STATE CA by 94612 <br /> ACCOUNTADDRESSToSEND FEES AND CHARGES: OWNER[-] FACILITYIBUSINESS❑ THIRD PARTYBILLINGII <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorizer/Agent,or <br /> Responsible Party and I acknowledge that all PERMITFEES,PENALTIES,ENFORCENIENTCHARGES and/or HOURLFCHARGES associated with <br /> this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.As the undersigned Owner, <br /> Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address, I hereby authorize the release of <br /> any and all results, reports, and other environmental assessment information to SAN JOAQUIN COCTNTENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Nicole Gregory SIGNATURE ~ <br /> TITLE TAXID# <br /> FAM nI 0; �� OWNER ID#: �I ),-,/���Q'� ACCOUNTM nDT�/` C ASSIGNEDTO: <br /> PR#: 7'kD T�2ZI ACCOUNTING COMPLETED BY: D DATE: <br /> n Lo <br /> SR TYPE /� PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST`# INVOICE# <br /> Work Plan 2903 523 $456.00 <br /> 2904 523 $760.00 / L{3 l`I`lhC61% t .�( �+'2-� -'19 <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />