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SAN Jk' .1UIN COUNTY ENVIRONMENTAL HEALTH L ARTMENT DATE July 31,2013 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM S 07/ 5*000711'SITE MITIGATION& LOP ,7711 SHADED AREAS FOR EHD USE ONLY OWNER ID# O O O CASE#CQ/`!7Z(� SRO647714 UNIT IV JRSlto�47 / OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORM TIO ; CHECK IF OWNER/S CURRENTLYON F/LEW/TH EHD PROPERTY OWNER NAME Port of Stockton (209)946-0246 FIRST MI LAST PHONE NUMBER BUSINESS NAME Port of Stockton E-MAILADDRESS OWNER HOME ADDRESS 2201 W.Washington St. CITY Stockton STATE ZIP CA 95203 OWNER MAILING ADDRESS 2201 W.Washington St. MAILING ADDRESS CITY Stockton STATE CA ZIP 95203 ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY X HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# OUNT ID P RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�RWQCB DTSC_EPA a-tg`l ]L3�; 105-3-111 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 Co No ❑ BUSINESS/FACILITY/SITEIPROJECTNAME Robert's Island SITE ADDRESS I PROJECT LOCATION 2717 W.Washington St. SUITE# BUSINESS PHONE CITY Stockton STATE CA 7jP 95203 BO=.FSUPERVISOR DISTRICT / LOCATION CODE Q / KEY1 LKEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS I 2201 W.Washington St. ATTENTION:OR CARE OF(OPTIONAL) MAILING ADDRESS CITY Stockton STATE CA ZIP 95203 SIC CODE APN It ( / .0 / O OMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLIN PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ERS Corp ATTENTION:OR CARE OF(OPTIONAL) MAILING ADDRESS PHONE 1600 Riviera Ave Suite 310 925-938-1600 CITY Walnut Creek STATE CA ZIP 94596 ACCOUNT ADDRESS 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,Aat/rorized Agent,or Responsible Party and 1 acknowledge that all PE&11IT FEES, PEN,11.71Es,ENFORCEmENTCHARGES and/or HODRLYCHARGES associated with this project will be billed to me at the address identified above as the ACCODNTADDRESS for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Autho izcd Agent,or Responsible 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 COUNTY 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) Leslie Shields, ERS Corp SIGNATUREOW p�A. S"IC-2s TITLE Project Scientist T-10* 36-4459849 / APPROVED BY I DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE f0ZZ 3 SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# `{E ^ RECEIVED BY WORK PLAN PE FEE:$ 31;& ---P5;58- 3 (f hc- K G'tla.r.V*k s• 3 75 .CZ -- - - -_- -