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San Aquin County Environmental Health -partment <br /> DATE2/6/12 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:CONPLETE TNEFOLLOW/NG PROPERTY OWNER INFORMAwm, - - WNERCURRE,vrcrawFu£wirn EHD � <br /> lamPERTYOWKERNAME (925)383-9517 <br /> Feat MI Last PNONENuMeas <br /> BUSINESS NAME EMAILADDRM <br /> Pacific Gas and Electric rOmk@pge.com <br /> Owner Home Address <br /> CRY STATE ZIP <br /> Owner Meiling Address <br /> 3401 Crow Canyon Road <br /> Mailing Address City Stat` Zip <br /> �5 San Ramon CA 94582 <br /> CORPORATION Ey INDIVIDUAL El PARTNERSHIP El FED AGENCY❑ OTNER❑ <br /> SITE MITIOATIONENVIRON MENTAL ASSESSMENT_VOWNYARY CLNINUP_WATER QUALITY_HW PI PELINE I NVEITIGATON LOP <br /> FACILITY ID INV# ACCOUNTID eiWRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�RWQCB_DTSC_EPA_ <br /> (AAa19ol �4koo3395 52ga8� 1649 <br /> FACILITY FILE CONPLETETHE FOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 129 <br /> Is this an EXISTING Business LOCATION but NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINEsWFAcatins/SSE NAME <br /> PG&E Tracy Service Yard <br /> SmAooR SURE# Business PHONE <br /> 502 E.Grant Line Road <br /> CRY STATE ZIP <br /> Tracy CA 95376 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ <br /> Mailing Address brDIFFERENThom Fac/W Address Attention:orCare Of(opIXwta/J <br /> Mailing Address City STATE ZIP <br /> SIC CODE AEN# COMMEM: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BusiNess NAME Attention:o Care Of(opfbae/# <br /> Parsons Tom Blanc <br /> Melling Addraee PHONE <br /> 100 W.Walnut Street 626-440-6067 <br /> CITY STATE ZIP <br /> Pasadena CA 91124 <br /> ACCOUNTAaagam for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENt: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all P£RMITFees, <br /> PEa'.ncna,EnFoace,U£nTCHASGes and/or Hot RLY CHARGEY associated with this operation will be billed to me at the address identified above As the ACCOH:VTADURm for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAGDIN COUNTY Ordinance Codes and/or <br /> standards and STATS..d/.r 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 DEPAR'I'NIE.NIas soon as t vmiable and a e same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRIM) Brian Eytcheson SIGNAWRE T <br /> TITLE TAX ID# <br /> Senior Geologist 943376767 <br /> Approved By Data Avcoundng Office Processing Complained By Data, <br /> SITE MITIGATION Assouw PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:.g <br />