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S#AQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR T <br /> SITE MITIGATION MASTER FILE RECORD INFORMATIO FORM <br /> "MFR"-GREEN FORM <br /> DAA 1 6/12/2018 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: C TffONIERATCV0WNnV00VME*WN END <br /> PROPERTY Rob Pennin ton PHONE <br /> 0,,,MN,,E ,p3, s. 916-596-2511 <br /> SusoaMNAME Energy Development Partnership, partnership E•MAL ADDRESS <br /> p p, a Delaware limited <br /> OYYNERHomEADDIIESE 2600 Capitol Avenue, Suite 430 ATTemON:-CAREOF(arab ) Rob Pennington <br /> D'T'' Sacramento _ STATE CA Zw.95816 <br /> OWNER MA/JNo Aoon= Same as above <br /> MALmADDRESS CrN STATE 2s <br /> ❑C.. ❑INo vmUAL ❑PARMeISRi ❑Gw®wlerrADemCY ®RMUKP SLE PARTY ❑OnrER <br /> ®ENVIRONMENTAL ❑EHD LOCAL VOLUNTARY ❑RWQCB LEAD- ❑RWQCB LEAD- ❑DISC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALRY(WDR) <br /> 2954 <br /> 2950 2953 29601352613527 2965 2959 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> 15 THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> IS THIS AN ETDSTINO PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINEasfFACIRgSrrelPaoJecr NAME 14800 west Schulte Road "PN•2(.4-7 LA C)—Z <br /> SRIF ADDIEBSIPRQECT LOCATRON 14800 West Schulte Road BUSINESS PHONE 510-410-1009 <br /> CRT Tracy STATE CA' 95377 <br /> Bomw OF Supow Oa Owwar LOCATION CODE KEH KEY2 <br /> MAl1No ADDRESS,IF DIFFEREM FROM FACIJRYADomm <br /> MMJM ADDIESS CRY STATE zip <br /> SICCDDE COwerr. <br /> RieaunToWs INFORMATION: <br /> Elu"NE86NAME Partner Engineering and Science "Tro'R1ON Nate Maroon <br /> MAaJNOADONED6 2154 Torrance Boulevard I PHONE 510-410-1009 <br /> cRr Torrance STATE CA ZAP 90501 maroon artneresi.com <br /> ACCOUNT ADDRESS TO SEND FRES AND cKAROES: OWNER❑ FACILITY/BUSINESS® REQUESTOR❑ <br /> BILLING AND COMPLIANCE.ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent, <br /> or Responsible Party and 1 acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CH IRGFS associated <br /> with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all <br /> applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FFDEIRAL Laws and RF.(:ULATIONS.As the <br /> undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,1 hereby <br /> authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provilled to me or my representative. <br /> Awurwr,NAME(PUCA�SEE PJUNT)�ea <br /> TITLE T.V�L{G((.IIS /LT L'C YUy�. SNM"TURE '" -- <br /> �1 L" TAI ID t <br /> FA/: `T� DNNetlofilll, I.v. 2 AxaJNrl: VCJ TT AIIaNEO TO: <br /> C✓CJ 17D ADODUNTWOC.COMPLETED� �,E S <br /> SR TYPE PE SC FEE INFO AAT REMTTED CHECKS RECVD BY DATE SERVICE REQUEST @MICE# <br /> PM <br /> Work Plan 2903 523 $456.00 <br /> 2904 523 $760.00 Iti LX lG t` <br /> Site Mitigation MFR 2-26-2018 <br />