Laserfiche WebLink
SAN J(O11N COUNTY ENVIRONMENTAL HEALTH FOARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 10/24/17 SHADED AREAS FOR EHD USE <br /> OWNER FILE.COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECRJFOWRERIS CaRREWTLYmpueWnn EHD <br /> PROPERTY Owens-Brockway Glass Container Inc. (Bill Boscacci PNONE <br /> OWNER NAME IRST ST (209) 836-8269 <br /> SUSINEsSNAME Owens-Brockway Glass Container, Inc. E-MAILADDRESS <br /> bill.boscacci o-i.com <br /> OWNER HOME ADDRESS 14700 Schulte Road AT ISmON:ORCARE OF lo"nowy Bill Boscacci <br /> CITY Tracy STATE CA LP 95377 <br /> OWNER MAILING ADDRESS Same as above <br /> MMDNGAOORESSCn,r STATE LP <br /> [ZCORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ® RWQCB LEAD- ❑ DTSCLEAO ❑FEDEPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATERQUALITY(WDR) 2858 2854 <br /> 2950 2953 29601352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No I& <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT NEW SCOPE OF WORK? YES IX No ❑ <br /> BUSINES81'ACILn1`18ITHPROJECT NAME Owens-Brockway Glass Container, Inc. APN` 209-24f 024 <br /> SITE ADDRESS I PROJECT LOCATION 14700 Schulte Road BUSINESS PHONE <br /> 209 836-8269 <br /> CITY Tracy STATE CA zip 95377 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME CKG Environmental, Inc. ATTENTION:ORCARE OFtOPr/oMILf <br /> Christina Kenned <br /> MAILING ADDRESS P.O. Box 246 PHONE 707 363-5740 <br /> CITY St. Helena STATE CA ZIP 94574 <br /> ACCOUNTADDRESB TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/Or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as Soon as it is available and at the Same time it is provided to me or my representative. <br /> APPUGANr NAME(PLEASEPRINT) Christina Kennedy/CKG Environmental, Inc. SIGNATURE <br /> TITLE President TABID* 68-0452250 <br /> FAS: OWNERID#:O/' I �a 24 ACCOUNT#: /I ASSIONEDTO: <br /> PR 8: �1/J� ACCOUNTING COMPLETED BY: ! f� DATE: l! Yf' <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST#D INVOICE# <br /> Work Plan 2903 1 523 $456.00 <br /> 2904 5 !_>,5� <br /> 23 $760.00 <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />