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SAN J UIN COUNTY ENVIRONMENTAL HEALTH E kRTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE 10/11/2018 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECKIFOWNERIsCURRENTLYONFILEWITH EHO X❑ PROPERTY PHONE OWNER NAME IRSi M1 LAST BUSINESS NAME Glenn Springs Holdings E-MAILADDRESS OWNER HOME ADDRESS ATTENTION:ORCAREOF(OPTIONAL) RogerSmlth CITY STATE ZIP OWNER MAILING ADDRESS P.O. Box 2148 MAILING ADDRESS CITY Houston STATE TX by 77252 ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- x❑ RWQCB LEAD- ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD ❑FED EPA LEAD 2950 2953 2960/3526/3527 2965 2959 2954 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ® No ❑ BUSINESSIFACILITYISITEIPROJECTNAME Simplot APN 19818008 SITE ADDRESS I PROJECT LOCATION 16777 Howland Road BUSINESSPHONE (209) 858-2511 CITY Lathrop STATE CAzIP 95023 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: REQUESTOR'S INFORMATION: BUSINESS NAME Geosyntec Consultants, Inc. ATTENTION Garrett Thornton MAILINGADDRESS 3043 Gold Canal Drive PHONE 916-637-8334 CITY Rancho Cordova STATE CA ZIP 95670 EMAIL GThornton@geosyntec.com ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR® BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES,PENALT/E.4,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated 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 information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL. Laws and REGULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/Site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my represe tive. APPLICANT NAME(PLEASE PRINT) Garrett Thornton SIGNATURE / �� TITLE Professional TAxID# 59-2355134 FA#. OWNER ID#: ACCOUNT#: ASSIGNED TO: PR#: ACCOUNTING COMPLETED BY: DATE: 1-443 IRE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2903 523 $456.00 4 1 / c. 3 2904 523 $760.00 / Site Mitigation MFR 2-26-2018