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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE 9/10/2014 MASTER FILE RECORD INFORMATION "MFR" GREENFORM SITE MITIGATION& LOP "�NADEO�NEy�EQ��HR usE�N(tY 1 OWNER 10# !� CASE# UNIT 'V I OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNERtSCURRENTLYONFILEWITN EHD QX PROPERTY OWNER NAME Stephen Beneto (916) 677-0817 r'ra;r P.11 J PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS I Beneto Inc. OWNER HOME ADDRESS CITY STATE LP OWNER MAILING ADDRESS 4080 Seaport Boulevard MAILING ADDRESS CITY STATE West Sacramento CZIPA I 95691 C_J CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION__`ENVIRONMENTAL ASSESSMENT-X-VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION,LOP FACILtTv 10# {NV# AccouNT IDPR#!RO# ASSIGNED Ei6PLOTEE 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 A NEW SCOPE OF WORK? YES ® No ❑ BUSINESSIFACILITVISITEJPROJEGTNAME Limited Phase 11 ESA SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE 10842 S Harlan Road 209 983-6970 CITY French Camp sTCA IP 95231 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ E MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPrIONALJ 10998 S Harlan Road J. Bernadicou MAILING ADDRESS CITY STATE ZIP Fre i ' Canly C'A 95231 SIC CODE APN# E.I.COMM '012 193-330-28 TNIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Pape Properties ATTENTION:ORCARE OF (OPFIONU) 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® BTI Cost i vs re AC69'/lwlar.n(;mr\T: 1,Ilk undersignul Applicant,certify that 1 am the(utter,Operoeu,Auth—i:ed Agent,or Responsible Parry anti 1 achno%%irdEe tint all I'a'tt.ufi/•'Ct::S, Pr;.v,tt.nt;s,Is•fuRr'EN6xK9t,trtr.Fs antilor I/Otrtu.rled with this project will b;billed to me at the address hlendfied above as theil<'L'ab'hT,I nnR6titi for dds she. I also certify that all intor•nnrtina provided un this applinuhat is true and correct;and[hell all regulated activities will he Periornted in accordance with all applicable SN JOAQUIN COU\ll'0"INANCE CDUFS andlor ST A\r). 2af.S anti S'TAIV and/or Frulk U.Laws and HEGNI„%TIO\S. As the undersigned thivier.Opervanr,AuUurri:rvl Agent,or RcrmV ible Portr for the project located above under facilitvAitr address,I du•rThy aalfrurixe die relerse of am'aad all results,reports,and ollar environmental asscumcra infonmiliou to SAS JOAQUIN'COUNTY E."VIRONME\fAL IIL\LTIIDEP,\ItTS1ES7;s s.wtl as it is available and at the same tinge it is provided m ure ur m7'represrntarive. }'aP�Pr"Pertics as>umcs respnnsibSti:;'limitctl to pern:it lees - hargc for rhe ESA.T ?op er is res,rnsihte for ani' penhici or enforcement eharl cs,or additional h0urlp c1KIrgeS,if any. /J C APPLICANT NAME(PLEASE PRINT SIG " TITLE f.✓��//ic-�ir�--�- /.�._�.�r� 1��4� ,C �TL'�'�r_�/�`� TAX ID# APPROveo 8Y DANE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE i FEE: