Laserfiche WebLink
0 • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE11/04/2014 MASTER FILE RECORD INS RMM6,T1 �MFR IS GREEN FORM <br /> H� <br /> SITE MITIGATION & LOP <br /> L001,n 4k, UNIT IV <br /> $MADE AREAS FOR EHO O OWNER ID# Clirrl-�•7 7V <br /> OO U <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK as OwNER M CuRRENuYONFILE wrrN EHD � <br /> PROPERTY OWNER NAME (925)415-6328 <br /> FMT MI Las, PHONENUMSER <br /> BUSINESS NAME E-NAILAODRM <br /> Pacific Gas and Electric Company M2Rq(@Pge.com <br /> OWNER HOME ADDRESS <br /> Cm STATE LP <br /> OWNERMMUNrs ADDRESS <br /> 3401 Craw Canyon Rd <br /> MAWNDADDRESICITY STATE LP <br /> San Ramon CA 94583 <br /> CcattwaTION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER I� <br /> SITE MITIGATION❑ENVIRONMENTAL ASSESSMENT❑VOLUNTARY CLEANUP✓WATER QUALITY QHW PIPELINE INVESTIGATION Q LOP Q <br /> FACILITY IDR INV# ACCOUNT ID IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�RWQCB_DTSC.�EPA_ <br /> vQ/9olG ;3838 52808 .lofhwvy <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO Q <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT NEW SCOPE OF WORK? YES Q NO ❑ <br /> BUSINESS/FACILITYISITEIPROJECT NAME PG&E Tracy Former MGP <br /> SITE ADDRESS I PROJECT LOCATION 502 E. Grant Line Road SUITE# BUSINESS PHONE <br /> CITY <br /> Tracy /� STAT <br /> VA J"95376 <br /> BOAROOFSUPERVISOR DISTRICT LOCATIONCODE Kul KEYI <br /> MMLING ADDRESS,IF DIFFERENT FROM F``�A.CIILITY ADDRESS ATTENTION:OR CARE OF/OPTIONAL) <br /> 11WtUNG ADDRESS CHY STATE LP <br /> SIC CODE APNE COMMENT: <br /> 5'U-27 ,08 <br /> THIRD PARTY BILLING I NFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Parsons ATTENTION:ORCAREOF(OPrIO,VALJrk Sarconi <br /> MAILING ADDRESS 2121 N. California Blvd., #500 PHONE 925�-941-3753 <br /> CITY Walnut Creek STATE CA ZIP 95776 <br /> ACCOUNT ADDRESS TO SEND FELE AND CHARGES: OWNERS FACILITY/BUSINESSO THIRD PARTY BILLINGD <br /> BILLING ND COMPLIANCE ACKNOyvI EnG%U r. 1,the undersigned Applicant,certify that I am the Owner,Operator,AuthadwdAgent,or Responsible Pam and I seta mledge that all PERI/ITPcas, <br /> PETaLT/Fd,ESFORreAtE\T CNdRGEB and/or 1pm&1 CnueEs associated%ith this project%ill Ix billed to me at the address idenfified above as the ACCOL:\TADDS for this she. 1 also terrify that all <br /> inform mm.provided on this application is true And correct;and that all regulated activities%ill be performed in accordance%ith all applicable SAN JOAQUIN COIN ORDINANCE CODES and/or <br /> STANDARDS nod STATE and/or FEDERAL Lasts and REGULATIONS. As the uadersigord O.-.e,,Operaror,Authorimd Ag m1,Or Responsible Parry for the project located above ander facility/the address,I <br /> hereby,Authorize the releae Of any and all Famlis,reports,and Other environmental assessment information to SAN JOAQUIN COUNTY ErcYmoNMENTALH N DEPANuNIF r as soon as it is available <br /> and al the same time it is provided Io me y repreuotative. <br /> APPLicaw NAME(PLFASlPMNI) �l LZat �lfC.�(,Q,S�'� SWruTUREQ [�JL��,p / -y I <br /> TmE.�ri NLT LL� CIIjO l '� TAR ID. f"1 ) 5 I IS�YLI� T <br /> APPROYE11D BY DATE ACCDmn1NG OFMCEPROCESSING COMPIEIED BY DATE <br /> SITE MITIDATI AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECKS RECEIVED BY WORK <br /> (IPLAN PE <br /> FEE:$ /�T CIF <br />