SITE INFORMATION AND CORRESPONDENCE_CASE 2

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SAN J _ AUIN COUNTY ENVIRONMENTAL HEALTH l ARTMENT DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION& LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE ff UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK iFOwNERIsCuaRENrLroNFILE wiTH EHD ❑ PROPERTY OWNER NAME CEMEX (916)941-2920 FIRST MI LAST PHONE NUMBER BUSINESS NAME CEMEX Tracy E-MAIL ADDRESS rmathur@somaenv.com OWNER HOME ADDRESS 5180 Golden Foothill Parkway, Suite 200 CITY STATE ZIP E1 Dorado Hills CA 95762 OWNER MAILING ADDRESS 5180 Golden Foothill Parkway, Suite 200 MAILING ADDRESS CITY STATE LP E1 Dorado Hills CA 95762 ®CORPORATION C1INDIVIDUAL ❑PARTNERSHIP EDGOVERNMENT AGENCY ElRESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT Y, VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP X FACILITY ID X INV* AccoUNT ID PR#/RO 0 ASSIGNED EMPLOYEE LEAD AGENCY.EHDRWQCB_DTSC_EPA_ 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 A NEW SCOPE OF WORK? YES ❑ NO BUSINESSIFACILRYISITEIPROJECT NAME RMC Pacific Materials-T0607700371 SITE ADDRESS I PROJECT LOCATION 30350 S. Tracy Blvd. SUITE* BUSINESS PHONE NA NA CITY Tracy STATE ZIP CA 95377 BOARD OF SUPERVISOR DIBTRiCT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPrtONAL) MAILING ADDRESS CITY STATE ZIP SIC CODE APN X COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION:OR CARE OF (OPT/ONAL) SOMA Environmental Engineering, Inc. Mansour SeiDehr MAILING ADDRESS 6620 Owens Dr., Suite A PHONE (925)734-6400 CITY Pleasanton STATE ZIP CA 94588 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILrrY/BUSINESS❑ THIRD PARTY BILLING® BILLING.AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant.certify that I am the Owner,Operator,Authorized Agent.or Responsible Parry and 1 acknowledge that all PERAtLT FEES, PE\4LTLFS,ENFORCENE\TCHARGES and/or HOCRLI'CHARGES associated with this project will be billed to me at the address identified above as the ACCOI iNT 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 Parry for the project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COT--'-----`-�-'--� xrn as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Bruce H. Eppler SIGNATURE TITLE Environmental Manager TAxID# 72-0296500 APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE $ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT tf CHECK ff RECEIVED BY WORK PLAN PE FEE: