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Jun. 4. 2013 3: 37PM TFPHNICON — No. 1305 P. 8 <br /> San *a wquin County Environmental Health Dial orirtment <br /> HATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> BHADP,p ARkAa PDR 1:MQR9E_QjU.'L OWNER IDO CASEUNIT IV <br /> OWNER FILE.COMPLETEPROPERTY OWNEW RESPONSIBLE PARTY/ArnwoAnom. Q,v 1p OWNER 041RRENrxr0w--rW/m EHO El <br /> PROPERTY OWNER NAME City of Tracy (200831-6460 <br /> RrV MI Lest PHONE NUMaim <br /> BuslNess NAatE E-irnK ADDRESS <br /> Owtwr Homo Address <br /> OR' Tracy STATE CA ZIP 95376 <br /> OwnarMauhmgAddrasa 333 Civic Center Plaza,Tracy <br /> M1aINng Ado—Oily 333 Civic Center Plaza,Tracy State CA ZIP 95376 <br /> ❑coitpoaAnow ❑INDMDuAL ❑PARTNERSHIP ❑GOVPANMENTAGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPRLINF INVESTIGATION_LOP <br /> FACILITY 10 If- INV# ACCOUNT ID PRIIIR00 . 4 <br /> askihso EMb'x66;'. •LFjtR'AOEH0YI.EHD RWQQB�DTSC`EPA <br /> FACILITY FILE: CoMPLEM BUSINESS/SITE/PROJECT INFORMATION: <br /> Is this a NEw Proleat LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> Is this an FmTmr.Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No ❑ <br /> 9U81Nws1FAaiLRY13rEIPRWEcTNA14E Delta Disposal <br /> SITE ADDRESS l PROJECT LOCATION 99 6th Street SUITE 0 BUSINESS PHONE <br /> STATE <br /> CITY TraCy CA "95376 <br /> BOARRm>FBIIPEriV180RDISTRICT Lowiol,lCooE KEY1 KEY2 <br /> mailing Address ffDjn%wFvrf m Fad1*AddVw" Mention;orCary Of(awona►I <br /> Mailing Address City STATE by <br /> SIC CODE "No COMMENT. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Props Owner R!!22nalble Party identified above. <br /> BuskNmmAME Technicon Engineering Services, Inc. Attention:areare Of!ac>i+a+l <br /> "lingAddram 4539 N.Brawley Avenue,Suite 108 PHONE 559-276.9311 <br /> CITY Fresno STATE CA 7jr 93722 <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BiLi jr4G AND COMPLIANCE ACKNOwLEDGMedT L the undersigned Applicant,certtry tbat I am thO Owner,Operalo.Aidl orizedAgmtr,orAcrponsible Perry and t acknowledge than rill PEF T,Ff,Es, <br /> PENALTIES,SNFOReBMBNTCNARGEs and/or HOORLYCNARGES associated with this project wilt be billed to ma at the address identified above as the AccoaNTAnnasSS for dds site. r*0 ecr1ifY that all <br /> information provided on fids application is true and correct;rind That all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> SiSUdards and STATE and/or FWEMF Laws and Regulations. As the uadersigDM Owner,Operator,Authorixed Agtn1,or Respousib)e Party for the project located above under facility/kite address,I <br /> hereby authors t the 116404 Of soy and all results,reports,and othtr environmental aw0menm iaformotion to SAN JOAQUIN COUNTY ENVIRONMENTAL 14EALTH DEPARTMENT as soon as it <br /> is available Rod at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PR,mT) Darren G.Williams SIGNATURE ` <br /> TrrLE PresidentICEO TAX Ib# 77-0209487 <br /> AyprevW BY Dere tFPAY=VENTTY-P'FF] <br /> ttlln9s Ptea:ttmf OamPletad ay Date <br /> Srre MITIGATION AwOUNT PAID DATE OF PAYMENT RECEIPT# CHECK# RECE.0 BY <br /> FEE:S <br />