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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE 10/3/19 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/FOwwERisCuRREArn_voNFILEw7N EHD PROPERTY Brown Sand, Inc. Pf011E OWNER IRST ST (209) 234-1500 BUsINEBsNAw Brown Sand, Inc. Root rt brownsandinc.com OWNER How ADDRESS 800 West Mossdale Road ATTEmDN:oRCAREOFtopwmL) CITY Lathrop sTA- CA ziP 95330 OWNER MAILING ADDRESS PO Box 1429 MAILING ADDRESS CITY Lathrop sTATE CA ZP 95330-1429 CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT A004CY ❑RESPONSIBLE PARTY ❑OTTR3I ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 2950 2953 2960/3526/3527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ Bus*aEss/FAcwm/STTE/PRO,IEmNmw Brown Sand, Inc. APN 239-040-07 SITE ADDRESS/PROJEOTLOCATION 800 West Mossdale Road B=NESBPHONE (209) 234-1500 cITY Lathrop STATE CAz1P 95330 BOARD OF SUPERVISOR DLSTR1oT LOCATIOIN CODE KEY1 KE12 MMuNG ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS PO Box 1429 MAILING ADDRESS CITY Lathrop STATECAzJP 95330-1429 SIC CODE CO-MEI : REQUESTOR'S INFORMATION: Gummll`lAw Brown Sand, Inc. ATTENTION MANJN6AD01m PO Box 1429 R-9 (209) 234-1500 CITY Lathrop STATE CA %330-1429 E"Robert@brownsandinc.com AccouNT ADDREw To SEND FEES AND cHARGm: OWNERVf FACILiTYBUSINESS❑ REQUESTOR❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERM/T FEES,PENALT[ES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address,I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D/EPARTMENT as soon as it is available and at the same time it is pro ed to my rep�tative. APPLICAIrt NAME(PLEASE PRM/T) / ��- W 8XINATURE TITLP / TAXID# y y_ 17 3 7 5 FA#: OWNER 10#: ACCOUNT#: ASSIGNED TO: PR#: ACCOUNTING O0WLUED BY: DATE: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2903 523 $456.00 2904 523 $760.00 Site Mitigation MFR 2-26-2018