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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM jl�DATE 7.15.2019 SHADED AREAS FOR EHD USE 10 OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/FOWNERIs Cf/RRENTLYONF/LEW/rH EHO PROPERTY PHONE OWNER NAME RSr Sr 209.235.9622 BUSINESSNAME Republic Services,Forward and Austin Road Landfills E-MAILADDREss OWNER HOME ADDRESS ATTENTION:ORCAREOF(OPnON4L) Don Litchfield CITY STATE zip OWNER MAILINGADDRESS 9999 S Austin Road MAILING ADDRESS CITY Manteca STATE CA ZIP 95336 ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GoveRNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ®RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 2950 2953 2960/3526/3527 2965 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 ❑ BUSINEs91FACIum/SITEIPRwEcTNAmE Forward Landfill APN 201-060-010-000 SITE ADDRESS/PRDJecrLOCATION 8610 Newcastle Road BUSINESS PHONE 209.235.9622 Cm Stockton STATE CA ZIP 95215 BOARD OF SUPERVISOR LOCATION CODE KEr1 KEY2 u ,IF DIFFERENT FROM FACILITY ADDRESS 9999 S Austin Road MAILING ADDRESS CITY Manteca STATE CAZIP 95336 SIC CODE REQUESTOR'S INFORMATION: BUStNN Arcadis US,Inc. ATTENTION Aaron Hook MAILINGADDREss 735 Tank Farm Road,Suite 150 PHONE 805.242.0159 CITY San Luis Obispo STATE CA ZIP 93401 ESL aaron.hook@arcadis.com ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR[5 BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agency or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,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 ormation to S J Q[1IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pr ovi ed o me or my r ative. APPLICANT NAME(PLEASE PRINT) Aaron Hook SIGNATURE TITLE Principal Scientist TAXID# FA#: OWNER ID M ACCOUNT M ASSIGNED TO: R#: ACCOUNTING COMPLETED BY: DATE: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Site Mitigation MFR 2-26-2018