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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE I1/5/13 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> Q!!--�� SITE MITIGATION&LOP <br /> S HAD EDAREADFOR EHD USEOHLV OWNER IDM CAGE# (v UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECR1f OWNERIS CURRENrLYONF/LEw1rH EHD ❑ <br /> PROPERTY ONNER NAME ( ) <br /> FIRST h!1 LAST PHONE NUMBER <br /> BUSINESS NAME Pacific Gas&Electric E-MAILADDRESS <br /> OWNER HOME ADDRESS 3401 Crow Canyon Road <br /> CITY San Ramon STATE CA ZIP <br /> 94533 <br /> OWNER MAWNO ADDRESS (sante as above)c/o Sharon L.Reackhof <br /> MAILING ADDRESS CITY STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# AccouNTID P IRO# ASSIGIIEDEMPLOYEE LEADAGENcY:EHD_RWQCB_DTSC_EPA_ <br /> r�4�1`tb►� AR00333 S '2, E)O0)1 1.) <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS TI ITS 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 IKI <br /> BUSINESSIFACILrTYISITEIPRQIECT NAME Vacant Lot <br /> SITE ADDRESS I PROJECT LOCATION 712 South Suramento Street SUITE# BUSINESS PHONE <br /> CRy STATO ZIP <br /> Lodi CA 65240 <br /> BOARD OF SUPERVISOR DISTRICT SLI LOCATION CODE O'z KEY'I KEY2 <br /> Mmuw ADDRESS,IF DIFFERENT FROM FACILRYADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> Terra Pacific Group Rick McCartney <br /> MAILING ADDRESS CITY STATE ZIP <br /> 201 North Civic Drive,Suite 135,Walnut Creek CA 94596 <br /> SIC CODE APN#045 32 Oft<L066 COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Terra Pacific Group ATTENTION:ORCARE OF(OPT1011ALJ <br /> Rick McCartney <br /> MAILING ADDRESS 201 North Civic Drive,Suite 135 PHONE <br /> 925-951-6000 x321 <br /> CITY Walnut Creek STATE ZIP <br /> CA 94596 <br /> ACCOUNTADDRESSToSEND FEES ANDCHARGES: OWNER❑ FACALITYIBUSINESS❑ THIRD PARTYBILLINGI] <br /> BILLING AND COMPLIANCE ACICNOWLEDGNENT; 1,the undersigned Applicant,cerlify-that I ant the(hrner, or Resporrsihle Par(p and I actmonledge that all PERMIT 1�6ES, <br /> PExinifS,F,%'rOx('L71EnTCH.U?GES and/or 11oURLYCIG(RGEs associated ssilh this project sill be billed to me at the address identified abose as the ACCOt1,vFADLIRESS for this site. I also ccrii(v that all <br /> information prosided on this application is true and correc(;and that all regulated activities still be perrorntcd in accordance%lith all applicable SAN JOAQLTN COL1Tv ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDER{L Lass and REGUL{TIONS. As the undersigned(hoter,Operator,Awhnrized Agent,or Recpmnvihle Party ror the project located above under fa[ilih/site address,1 <br /> hereby nulhorire(he release of any and all results,reports,and other cmirontummi nsscssnteot information to S.\\JOAQULN COL:,,,TY ENVIROS>LE,I:ALHEALIH DEPARIMEN-l' 'smn as It is avnitable <br /> and at the same time it is prosided(o meor my represenlalive. <br /> APPLICANT NAME(PLEASE PRINT) .b.t L�� _S/�J //.`i(L�C (G. SIGNATURE /7 4 / 1_<_----�—' <br /> / <br /> TITLE rp �G�.� K/C- Tax IDM <br /> I / 111/ () �'/)l!' I <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE REO EI PT CI1 EC tI RECEIVED BY WORK PLAN PE <br /> FEE: <br />