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: y _ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE IF9110/2014 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SITE MITIGATION Sit LOP $J,�i RED��g�" Qg_EHD USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHEr-KiFOwNERisCuRRErrcroNFuewlrH EHD FX PROPERTY OWNER NAME Stephen Beneto (916)677-0817 FIRST 1A! L..7ST PHONE NUMBER BUSINESS NAME BelTeto Inc. ENT E-MAILAoonESS OWNER HOME AoDRES9 RECEIVED CITY STATE ZIP SAN JOAQUIN COUNTYi OWNER MAILING ADDRESS ENVI R O M EN TAL 4080 Seaport Boulevard HEALTH DEPARTMENT MAILINGAmilesSCITY I STATE zip i West Sacramento CA 95691F ZI i CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSISLEPARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_1'IW PIPELINE INVESTIGATION_LOP FACtLtty lO# INv# ACCOUNT ID PR#IR@lh ASSIGNED EMPLOYEE., LEAD AGENCY:EHD ` RWQCB DTSC_EPA_ JOhFN� FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED I3Y THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 2 IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ BUSINESSIFACIUTY1srrEJPROJECTNAME Limited Phase It ESA SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE 10842 S Harlan Road 209 983-6970 CITY French Camp SCA zip 95231 BOARD OF SUPERVISOR DISTRICT LOCATION CODE C lMy KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FAOILrtYAODRESS 1 1 ATTENTION:OR CARE OF/OPTIONAL) 10998 S Harlan Road J. Bernadicou MAILING ADDRESS CITY STATE ZIP French am A 95231 SIC CODE APN# COMMENT: X012 193-330-23 THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENTFROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Pape Properties ATT'ENTIoN:oR°ARE OF(OPr10HAL) Daniel Radonski MAILING ADDRESS PHONE PO Box 407 (541) 341-3344 CITY STATE ZIP Eugene OR 97440 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® UILtd NG AND COSYLLSR[•E ACKN'01yl,t:O(;air%T: I,lite undersigned AIVI)Rcaat,certify that 1 ant to fhweer,Operrrinr,Aailrarited Agan,nr Respunsihte Pane and I actirwivlalge(har ail PFivarl�£ILT, Ptmit.rm's',13,YFoacewTNrCILiRr7t3 nn11101'flOURI.Y 11,11(6£•S 11550eilitell{cilli this prolmtMill lie billed IU ma at cite address l0endaed above as theACCU1kVrr1 noar-w ror this,site. I also certify thaI all Inlbrination pl'oVided Oil this appiicatiMt Li true and correct;inut chat all resUlagell rn'tivitics will he performed In accardatica hili all Itpplicuble SANJOAQUIN C00%TT Opin\'Amm Cours untWr STA\Da ROS and STATE.and/or FF,OE.RAI,Laws and RF.CI11nsTTOXS,As lilt undersigned(hivier,Op,rarur,AuchariLal Agent,ry Rcgwns/her Par(;'Snr the project located:dove under facility/site address,I hrrcby all lhorize ale role sr of arty and:dl resolts,reports,and other envirolmhenlal assv3suterlt inforimlion to SAS JOAQUn COLZTY ENTIlto it-NIAL IIL\LTII DF.PABT:1tE\Y;c w(A.9S it IS tn'ailuhle and at the same tinge it is provided ru uie ur myrepresenfativr. Pape Properties assumes responsibiMy Urnited to pern:it fim hu6es for the ESA,T op er 3s res msible for ant• penalties or enforaenunt charges,or ad—d^itiion-al,hourly charges,ifany. ---�^^---,---'�� APPUCANT NAME(PLEASE PRINT) / l� t, L[% SIG TITLE �C-if�.I/.t��B�i�'��- •�riia>� P- J L)�7�7"�,1/-f L�r�/.�•�- TAx I D# AppROVEO BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE r L E MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHE K# RECEIVED HY WORK PUN PE:$ 3r 3q� Q-2z-/y e ,� � '3 4�vL+Is�L - � _>: