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ECEIVF` SAN QUIN COUNTY ENVIRONMENTAL HEALTH. ARTMENT DATE 5/21/2013 MASTER FILE RECORD INFORMATION "MFR" 2 3 201PREEN FORM (�t�'�p . SITE MITIGATION& LOP SHADED AREAS FOR EHDl15E ONLY OWNER ID# CASE# `•,PJfIRONM NTALFMIT IV �Er?VICES OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER ISCuRRENrLYON FILE W/rN EHD El PROPERTY OWNER NAME Gary Dobler (209) 482-2275 FIRST MI LA; PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS OWNER HOME ADDRESS 276 W. 20th Street CITY Tracy $TATE ZIP CA 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 X_ VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP [FAC�ILITYID �INV# ��AC..UNT�ID �PROIR`DlllASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB DTSC_EPA_ 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 ANEW SCOPE OF WORK? YES ® No ❑ BUSINESS/FACILITY/SITE/PROJECTNAME Chevron Environmental Management Company(CEMC)/ Former Tracy Pump Station SITE ADDRESS/PROJECT LOCATION 14821 W. Grant Line Road SUITE# BUSINESS PHONE 925-790-6431 CITY Tracy STATE CA ZIP 95304 BOARD Of SUPERVISOR DISTRICT LOCATION CODEF—J KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) 6101 Bollinger Canyon Road,Room 5384 Michael Oliphant MAILING ADDRESS CITY STATE ZIP San Ramon CA 94583 SIC CODE APN# COMMENT: 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 MAILING ADDRESS 1000 Broadway,Suite 675 PHONE 510-466-7148 CITY Oakland STATE CA ZIP9 4607 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FAC ILITYIBUS[NESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNOWLE DCM ENT: I,the undersigned Applicant,certify that I am the fhrner,Opentttrr,:ItudtoriceJ:lgent,or Respmaih/e Pare and I acknowledge that all PER.it/T FEES, PEN LHES,EVFORCEMEN7'CIL-INGEs and/or 110URLYCHARGES associated with this project will be billed to me at the address identified above as the Accol v7.dm)RE.S.1'far this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities(sill be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODE and/or STANDARDS and STATE and/or FEDERAL Lmvs and REGULATIONS. As the undersigned Otrrier,Operutor,Autlwrized.-Igeut,or RetpoiLvible Party,for the 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 CotINTY ENy'IRONMENTAL IIEALT i DEPARTMENT as soon as it is available and at the same time itis provided me or my representative. f � APPLICANT NAME(PLEASE PRINTT) Sean Gehlke SIGNATURE TITLE SAIC Project Geologist TAX ID# 20-1659855 APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PUN PE FEE: