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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 11(5/13 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOO EHD UBE ONLY OWNER ID# CASE# <br /> UNIT IV <br /> S2oc�Gg W/S <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER ISCURRENTLYON FILE WIrH EHD <br /> PROPERTY OWNER NAME ( ) <br /> FiRSi All LAST PHONE NUMBER <br /> Busmss NAME Pacific Gas&Electric E-MAIL ADDRESS <br /> OWNER HOME ADDRESS 3401 Crow Canyon Road <br /> CITY San Ramon STATE CA LP <br /> 945,93 <br /> OWNER MAIUNO ADDRESS (same 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 IDN INV# AccoUNTID PRNIRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSCEPA_ <br /> Bol qvl) �5z�C) <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS TI IIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED UY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YEs ❑ NO ❑ <br /> BUSINESSIFACIUTYISITE/PROJECT NAME %1,,ca,Lot <br /> SITE ADDRESS I PROJECT LOCATION 712 South Sacramento Street SUITE# BUSINESS PHONE <br /> STACrry Lodi CA 6 240 <br /> BOARD OF SUPERVISOR DISTRICT 'L-I, LOCATION CODE O'Z KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITYADDRESS 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# COMMENT: <br /> 045-32,60 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Terra I'aCIf1C Groep ATTENTION:ORCARE OF(OPTIONAL) <br /> Rick McCnrine <br /> MAILING ADDRESS 201 North CIVIC Drive,St11te 135 PHONE <br /> 925-951-6000 x321 <br /> Cm Walnut Creek STATCAE zip <br /> z <br /> ACCOUNTAODREssToSEND FEES ANDCHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTYBILLINGIS) <br /> BILLING AND COMPLIANCE ACKSOIPLEDG\IEN7: 1,the undersigned Applicant,certi6-that I ant the(Amer,Open Nor,.1 ullrori,oJ,l,ginl,or Responsible PRr(1•and I aclatms ledge that all FERIIII FEES, <br /> PExtmu,F,%I-ORc'E7/EAT CH.tRGES andlor 1101'RLI CHARGES associated ssith this project sill be bitted tonic at[headdress identified abme as the AcconvrAiwms for this site. f also cerlifs'That all <br /> information prosided on this application is true and correct;and that all regulated actisitics sill be performed in accordance ssith all applicable SA\JOAQL7S COL1'TY ORDINANCE CODES and/or <br /> STANDARDS and STATE andlor LEDER%L Lasss and REGCL\TIOSS. As the undersigned Ou7rer,Operator,Anthori;eel Agent,or Respomib/e Pur!)•for the project located abose under fa IiGh/site address,I <br /> hereby nuthoriie the release of any and all results,reports,and other em iroamenlal assessment information to S.\S LIiNE\ <br /> JO.%QLN COLS I'EmwMIAL HEALTH DEPARI MES/ SOOn as It Is available <br /> anda'the same time it is prosided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT /-7l l{ / (/! i+..C �c� SIGNATURE <br /> s <br /> TITLE / ) TAXID# 1�r� �I =� /!' <br /> TITLE <br /> BY DATE ACCOUMING OFFICE PROCESSINO COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY =WORKPLANFEE:$ <br />