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San J]Win County Environmental Health Oartment <br /> DATE 8/5/11 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> SRa EDArIE HD U6 Y OWNER IDM CASE# UNIT IV <br /> OWNER FILE:COMPLL-TETNEFOLLOw/NOPROPERTY OWNER/NFORMAT/ON.' CHECAIVOWNERCURREh7LYoNFaewnHEHD � <br /> PROPERTYOmERNAME City of Tracy (209) 631-6000 <br /> First MI Last PHONENUMBER <br /> BuslNEss NAME Chevron Environmental Management Company(CEMC) E-MaLAooREes <br /> 92 1A <br /> Owner Home Address N/A <br /> city VQFF <br /> STATE LP <br /> Omar Melling Address 333 Civic Center Plaza <br /> Melling Address City Tracy Slate CA ZIP <br /> 95376 <br /> CORPORATIONIKI INDIVIDUAL El PARTNERSHIP❑ FEDAGENCY❑ OTHER❑ <br /> SrrE MM"TNTN x ENVIRONMENrAL AMB9 ENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INviumannoN_LOP <br /> FAcu_rrYID# INV# AccouNTIO PR#IRO# AseIGNeo EMPLOYEE I LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE COMPLETETHEFOLLOw/NG BUSINESS/FACILITY/SITE tNFORMATlom <br /> Is this a NEW Business LOCATION notpresillwely regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ N/A <br /> Is this an EASTING Business LOCATION but NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINESWACILITY/SITEMgME Chevron Environmental Management Company(CEMC) <br /> SITEADUReas Chestnut Avenue/Willow Way/Palm Cir SUITE# BUSINESS PHONE <br /> 925-790-6431 <br /> Cm Tracy STATE CA LP <br /> 95376 <br /> BDARDOFSUPERVISORDIeTNICT LOCATON CODE Kul KEY2 <br /> Mall Ing Add Deas/rDIFFERENT#em FaolllfyAdrlraee Attention:orCara Of foPitiareM <br /> 6101 Bollinger Canyon Road,BRI-X/5381 Michael Oliphant <br /> Mailing Address City San Ramon STATE 21P <br /> CA 94583 <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner orFacillty Operator identifiedabove. <br /> BUSINESSNAME SAIC Energy,Environment,and Infrastructure,LLC AOent"OE orCera Or/aptlns"ll Sean Gehlke <br /> Mailing Address 1000 Broadway,Suite 675 PHONE <br /> 510-466-7148 <br /> Cm Oakland STATE CA 7LP 94607 <br /> Aenrv_rNrdeeseaR for fade and chargee OWNER FACILITY/BUSINESS IRC PARTY BILLI <br /> BILLING AND COMPLIANCE ACKNOWLEDGME.": 1,the undersigned Applicant,rectify that I con the ON'I(er,Opermar,or Authorized Agent of this Business,and I acknowledge that all PERMITFEEs, <br /> PENALTIES,R:VFORC£N£A'T CHARGESand/or HOL'RL ICHARGES associated With this Operation WIB be billed to me at the address identified above as the ACtVU.h']'ADDRESS for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated a th dies will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes mad/or <br /> Standards and STATE and/or FEDERAL Laws and Regulation.As the Undersigned owner,ollernlar,Or agent Of the property located at the above facility/site address,I hereby nuthoruE the release of <br /> one and all res alts and environmen lel assessment information to SAN JOAQUIN COU N I l'EN'VI RONM ENTAL 11 EALT H DEPARTMENT'as soon as it is,available and at the same time it u <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASEPRINT) Sean Gehlke SIGNATURE <br /> TITLE SAIC Project Geologist TAX ID# <br /> rwadB Deb Aecounting ORke Procuensis,Cam ludaul Ely Date <br /> 91TE MITIGATION AMOu Nr PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />