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SAN JO,.aUIN COUNTY ENVIRONMENTAL HEALTH DL. ARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 10/11/2018 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IsCURRENnYON FILE wrH EHD x❑ <br /> PROPERTY PHONE <br /> OWNER NAME FIRST M, LAST <br /> BUSINESS NAME Glenn Springs Holdings E-MAILADDRESS <br /> OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPT'ONAL) Roger Smith <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS P.O. Box 2148 <br /> MAILING ADDRESS CITY Houston STATE TX ZIP 77252 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑X RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESS/FACILITYISITE/PROJECTNAME Super Store Industries Lathrop Distribution Center APN 19816026 <br /> SITE ADDRESS/PROJECT LOCATION 16888 McKinley Avenue BUSINESSPHONE (209) 858-2671 <br /> CITY Lathrop STATE CAzIP 95330 <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 /> REQUESTOR'S INFORMATION: <br /> BUSINESS NAME Geosyntec Consultants, Inc. ATTENTION Garrett Thornton <br /> MAILING ADDRESS 3043 Gold Canal Drive PHONE 916-637-8334 <br /> CITY Rancho Cordova STATE CA ZIP 95670 EMAIL GThornton@geosyntec.com <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR® <br /> BILLING AND COMPLIANCE ACKNOSN'LEDGMENT: I, the undersigned Applicant,certify that I am the Owner, Operator,Authorizer/Agent, <br /> or Responsible PartI, and I acknowledge that all PERMIT FEES',PENALT/Es,ENFORCEMENT CHARGES and/or HOURLY CHARGES 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 COUNTS ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br /> undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br /> authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEAL.TFI DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT Garrett Thornton SIGNATURE <br /> TITLE Professional T-ID# 59-2355134 <br /> FA#. � �.)Z- NER IDX: ACCOUNT#: ASSIGNED TO: <br /> PR#: O ACCOUNTING COMPLETED BY: DATE: <br /> q'ySR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> 2903 523 $456.00 <br /> Work Plan 2904 1 523 $760.00 ��t0 I3� S 1-L�L�-79 3 <br /> Site Mitigation MFR 2-26-2018 <br />