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San Aquin County Environmental Health apartment <br /> DATE11l IIZI�2 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> 1 SITE MITIGATION & LOP <br /> SHADEOAIR sFm EHDUWONLY OWNER ID# CASE# SaY/)DC UNIT IV <br /> OWNER FILE:CowmETE INEFOLLOW/NG PROPERTY OWNER INFORMAT/OLN. CHElcKlr OWNER CuRREHrzromFuEwm+EHD ® <br /> PROPTNTYa4Np1NA1de (925)383-9517 <br /> Fest MI Last PHONENUTAeEN <br /> Business NAME E,1INLADDRess <br /> Pacific Gas and Electric(PG&E) rOrnkame.corn <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> 3401 Crow Canyon Road <br /> Mailing Address City State Zip <br /> San Ramon CA 94583 <br /> CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY OTHER[I <br /> SITE MITIGATION -/ ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FAOIUTYID# INV# ACCOUNTID f"1R0# ASSIGNED EMPLOYEE LEAD AGENCY:EHD tRWQCB_DTSC_EPA_ <br /> ffibo 19 oro 57 <br /> o G <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No <br /> Is this an EXISTING Business LOCATION luta NEW TYPE of regulated Business? Yes ❑ No <br /> BUmNESs/FACILRY/SnE NAME <br /> PG&E Tracy Service Center <br /> $READDRESS SURE# Busies $PHONE <br /> 502 E. Grant Line Road <br /> CRY STATE ZIP <br /> Tracy CA 95376 <br /> BOAROOFSUPERWSORDISTRICT LOCATION CODE KEPI KEY2 <br /> L <br /> Mailing Address NDIFFERENT#nm FwAllyAddress Attention:orCare Of(op#anaQ <br /> Mailing Address City STATE zip <br /> SIC CODE APN# i2 !(>— /\U COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> BUSINESSNAME Attention:orCare Of(opVlortal) <br /> Parsons Tom Blaney <br /> Mailing Address PHONE <br /> 100 W. Walnut Street 626-440-6067 <br /> CITY STATE ZIP <br /> Pasadena CA 91124 <br /> Acca NTAaaaEaa for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,ceraf,that 1 am the Owner,Operator,or Authonzed Agent of this Business,and 1 acknowledge that all PER.U(TFEFS, <br /> FE.VALnEs,C'.NFORCENEATCHAEG; S and/or Hol-RLI'CHARGES associated with this Operation of be billed to me at the address identified above as the ACCOUATADDHESS for this site. I also certify that <br /> aD information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNC(Ordinance Codes and/or <br /> Standards aad STATE and/or FEDERAL Laws aad Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT As soon it is vailable ad at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASEPRINT) Brian K. Eytcheson, P.G. SWNATUW <br /> TITLE TAX ID# <br /> Princioal Geologist 943376767 i�, <br /> ApprovedB Dab Aaoolaltlng OMos Processing CompMMd By �. Date 4V 12 <br /> IF <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:; <br /> �9 <br />