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BUSINESS NAME Ramboll Environ <br />CITY 94608 Emeryville STATE CA ZIP <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERE FACILITY/BUSINESSE THIRD PARTY BILLING71 <br />ATTENTION: ORCARE OF (OPTIONAL) Jason Kane <br />MAILING ADDRESS 2200 Powell Street, Suite 700 510-420-2547 PHONE <br />SAN JuAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH ENO <br />PROPERTY <br />OWNER NAME <br />Reyes Coca-Cola Bottling, L.L.0 PHONE <br />847-227-6764 FIRSF MI L4ST <br />BUSINESS NAME Reyes Coca-Cola Bottling. L.L. C. E-MAIL ADDRESS rgreiber@reyesholdings.com <br />OWNER HOME ADDRESS 6250 N. River Road ATTENTION: ORCARE OF (OPTIONAL) Robert Greiber <br />crry Rosemont STATE IL ZIP 60018 <br />OWNER MAILING ADDRESS 6250 N. River Road <br />, <br />MAILING ADDRESS CITY STATE IL ZIP 60018 Rosemont <br />El CORPORATION <br /> El INDIVIDUAL <br /> <br />0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY OTHER (LLC) <br />P1ENVIRONMENTAL . EHD LOCAL VOLUNTARY IN RWQCB LEAD — El RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />III DISC LEAD I. FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No <br />BUSINESS/FACILITY/SITE/PROJECT NAME Coca-Cola Bottlin g Company APN• ' 117-360-41 <br />SITE ADDRESS! PROJECT LOCATION BUSINESS PHONE <br />146761 Pinal Drive 800-647-2653 <br />CITY Stockton STATE CA ZIP 95205 <br />BOARD OF SUPERVISOR DISTRICT 1 LOCATION CODE li KEY1 KEY2 <br />MAILING ADDRESS ,IF DIFFERENT FROM FACIUTY ADDRESS <br />same as above <br /> <br />MAILING ADDRESS CITY <br /> STATE ZIP <br /> <br />SIC CODE COMMENT: <br /> <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BILi ING AND CONDI I kNCE ACKNOIN I EDGMENT: I, 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 ACCOUNT ADDRESS 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 ST kND kRDS 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 S ‘N JO‘Qt IN COUNTY ENN IRONNIENT <br />Em HI 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) QA0tAIS 6 6•AI1 (Z-15J SIGNATURE <br />TITLE -7) <br /> <br />TA.,.# <br /> <br />FA #: 4602_,.,..i _ , OWNER ID #: c2.1...<721 ACCOUNT #: ARL)04/54.11.07 ASSIGNED TO: <br />PR #: ?leo <br />2-+O <br />ACCOUNTING COMPLETED BY: <br />6-- <br />DATE: <br />I, 30 i <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 $ 4 a OA) Lit 007 't-r)' <br />Site Mitigation MFR 29- )00C 8-1-2017