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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE5/21/2013 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNERID# �Ij xb t. �q CASE# 47 z r UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNERISCURRENTLYONFILEWITH EHD PROPERTY OWNER NAME Gary Dobler (209) 482-2275 FIRST MI LAST PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS OWNER HOME ADDRESS 276 W.20th Street CITY Tracy STATE CA ZIP 95376 OWNER MAILING ADDRESS Same as home address MAILING ADDRESS CITY STATE zip ❑CORPORATION ®INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT.�L_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FacaITYID# INV# AcccuNrlD PR RO# ASSIGNED EMPLOY EE LEAoAGENcY:EHD_RWQCB_DTSC_EPA_ 1314131 t VSs � Jol{N� FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: ISTHIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ® No ❑ BUSINEss/FACILITY/SITEIPROJECT NAME Chevron Environmental Management Company(CEMC)/Former Tracy Pump Station SITE ADDRESS I PROJECT LOCATIONSUITE# BUSINESS PHONE 14821 W. Grant Line Road 925-790-6431 CITY Tracy STATE CA zIP 95304 BOARD OF SUPERVISOR DISTRICT C LOCATION CODE > KEY') KEY Z MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) 6101 Bollinger Canyon Road,Room 5384 Michael Oliphant MAILING ADDRESS CITY STATE ZIP San Ramon CA 94583 P'996p- APN#� 1q,61 COMMENT: O - THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME SAIC Energy,Environment,and Infrastructure,LLC ATTENTION:ORCARE OF(OPTIONAL) Sean Gehlke MAILINGADDRESS 1000 Broadway,Suite 675 PHONE 510-466-7148 CITY Oakland STATE CA ZIP 94607 ACCOUNTADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,:I ittltorizedAgent,or Responsible Party and I acknowledge that all PERDIIT FEE.$ PENALTIES,ENFORCEMENT C10RGES and/or 1IOLrRLYC11.4RGES associated i ith this project[till be billed to me at the address identified above as theACCOUNTAbORESS 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[Nidi all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANTIARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Onvier,Operator,elutborized Agent,or Responsible Party'for die project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUN-Ty ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Sean Gehlke SIGNATURE TITLETAX ID# 20-1659855 SAIC Project Geologist APPROVED BY OATS AUNTING OFFlCE PROCESSING COMPLETED BY DATE CCO SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WO�t PLAOPE FEE:$ /Jv. /Q