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SAN JO,*^UIN COUNTY ENVIRONMENTAL HEALTH r"PARTMENT <br /> SITE MITIC .ION MASTER FILE RECORD INFOF_ ,{TION FORM <br /> "MFR"-GREEN FORM <br /> DATE 9/2/2016 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/FOWNER/SCURRENTLYONF/LEW/TH EHD <br /> PROPERTYSteve I I Cortese PHONE <br /> OWNER NAME FIRST I M1 I LAST <br /> BUSINESS NAME Cortese Real Property E-MAIL ADDRESS Steve@corteseinvestment.com <br /> OWNER HOME ADDRESS 21 Lafayette Circle, Suite 200 ATTENTION:ORCARE OF(OPTIONAL) <br /> CITY Lafayette STATE CA ZIP 94549 <br /> OWNER MAILING ADDRESS 21 Lafayette Circle, Suite 200 <br /> MAILING AD DRESS CITY Lafayette STATE CA ZIP 94549 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— Q RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <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 <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESS/FACILITY/SITE/PROJECTNAME Former Holly Sugar Facility APN: <br /> SITE ADDRESS/PROJECT LOCATION 20500 Holly Drive BUSINESS PHONE <br /> CITY Tracy STATE CAZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE — 1COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Langan Treadwell Rollo ATTENTION:ORCARE OF (OPTIONAL) Jeff Ludlow <br /> MAILINGADDRESS 555 Montgomery Street PHONE 415-955-5200 <br /> CITY San Francisco STATE CA zIP 94111 <br /> ACCOUNT ADDRESS TO SEND 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,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES,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 Parry 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 repr sentaYve. <br /> APPLICANT NAME(PLEASE PRINT L(,��� ! �/.-' SIGNATURE --- <br /> TITLE TAx ID# 22-3167382 <br /> FA#: OWNER ID#: ��d ACCOUNT#' A/ l <br /> � u7 J ASSIGNEDTO: <br /> Wdo�i �b <br /> PR#: ACCOUNTING COMPLETED BY: DATE: q /� <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />