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SAN--AQUIN COUNTY ENVIRONMENTAL HEALTH &--PARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 03/23/17 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/F OWNERIS CURRENTLYONF/LE W/TH EHD <br /> PROPERTY Target Corporation-Property Owner Philli s 66 Company-Responsible Party/ PHONE Linda <br /> OWNER NAME I Arcadis U.S. IncTonsultant ST 612.761.6385 Opperman <br /> BUSINESS NAME EMAIL ADDRESS <br /> Target Corporation Constructison.Environment@target.com <br /> OWNER HOME ADDRESS N/A ATTENTION:ORCARE OF(OP77ONAL) <br /> CITY N/A STATE zip <br /> OWNER MAILING ADDRESS <br /> PO BOX 111 <br /> MAILING ADDRESS CITY Minneapolis,MN,55440 STATE zip <br /> El CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY © RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESsIFAcILITY/SITE►PRwECTNAME Case:Unocal#6981;RWQCB Case#390204;76PP#351515 APN: 108-160-04 <br /> SITE ADDRESS I PROJECT LOCATION 4707 Pacific Avenue BUSINESS PHONE <br /> 707.843.6032 Arcadis <br /> CITY Stockton,CA 95207 STATE zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KW KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 100 Smith Ranch Road,Suite 329 <br /> MAILING ADDRESS CITY San Rafael,CA 94903 STATE zip <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:OC RA (QP 3Tl L115 <br /> Arcadis U.S. , Inc. Ke . 3515 <br /> MAILINGADDRESS 100 Smith Ranch Road, Suite 329 PHONE 707.843.6032(Jennifer Granborg <br /> CITY San Rafael, CA 94903 STATE ZIP <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILfrY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Parry and I acknowledge that all PERM/T FEES,PENALT/ES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site.I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address,I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Katherine Brandt SIGNATURE `S ` L <br /> TITLE Professional Geologist TAXID# 57-0373224 <br /> FA 0: J/ OWNER ID A:0 <br /> tvdo 2,6/Z ACCOUNT#: AP ul! I l 7 M / , ,'Z,7 ASSIGNED TO: <br /> PR/: [�lu��/771 ACCOUNTING COMPLETED BY: DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />