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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATEF�_ <br /> MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> DATE <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USEOHLY OWNER IDX CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER 15 CURRENTL Y ON FIL E W/TH E H D <br /> PROPERTY OWNER NAME ( ) <br /> FAST 411 LAsr PHONE NUMBER <br /> BUSINESS NAME Pacific Gas&Electric E-MAILADDRESS <br /> OWNER HOME ADDRESS 3401 Crow Canyon Road <br /> CITY San Ramon STATE LP <br /> CA 94583 <br /> OWNER MAILING ADDRESS same as above)c/o Sharon L.Reackhof <br /> MAILING ADDRESS CITY STATE LP <br /> Il CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID INV# AcCOUNTID PR#!RO# A991GNEDEMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA <br /> _ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS TI IIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY TIIE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No (KI <br /> BUSINES9IFACILITYISITE/PROJEGT NAME Vacant Lot <br /> SITE ADDRESS I PROJECT LOCATION 712 South Sacramelllo Slrect .SUITE# BUSINESS PHONE <br /> CITY Lodi STATE ZIP <br /> C'A 65240 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> Terra I'36FIC 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 /> 11 045-32-600 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME-ferrn Pacific Group ATTENTION:OR CARE OF (OPTIONAL) <br /> Rick NicC•artne <br /> MAILING ADDRESS 201 Not III CIVIC Dr i%e,Suite 135 PHONE <br /> 925-951-6000 x321 <br /> CITY Walnut Creek zipSTA <br /> CA 94596 z <br /> ACCO UNT AD DR ESS TO 8 EN D FEES AND C HARG ES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTYBILLINGE) <br /> BILLING AND COMPLIANCE ACKNOWLEDGNE\7: 1,the undersigned Applicant,certify that I mn the(hrner,Opanrtnr,.Iutlrori,c,Llgrnl,or R0Ponsihle Party and I actalouledge that all PERVIT FEES, <br /> PEA:1L)IES,F.ATORc'LmnrCH.tR(;ES andfor 110URLYCILIRCES associated pith this project sill be billed to me at the address identified above as the Ac(or.vrADDRESS for this site. I alio certify(hat all <br /> information provided on this application is true and correct;and that all regulated activilics will be perforated in accordance with all applicable SAN JGAQ11S COINn'ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or I EDERlL Lams and REGULATIONS. As the undersigned(htwer,Operator,`I uUmriZ d Agent,or RLIPauihle Purl,for the project located above under faSiGty/site address,1 <br /> hereby anthoriie the release of any and all results,reports,and other cnvironmental assessment information to SAN JOAQl1LC Coumv EAYIR0.xmESTAL HEALTH DEPART?IL.%r 4 soon as It Is available <br /> and at the same time it is provided to me or my representative. / <br /> 'l 1 <br /> APPLICANT NAME(PLEASE PRINT f 7 L f J )�)(���_(�(t✓l,C�� SIGNATURE 777 <br /> TITLE / } <br /> TAXID# <br /> APPROVED BY DATE ACCOUNTING IMCE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ <br />