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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 7.15.2019 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNER Is CuRRENTLYONFILE WITH EHD EN <br /> PROPERTY PHONE <br /> OWNER NAME FIRST Ml LAST 209.235.9622 <br /> BUSINESS NAME Republic Services,Forward and Austin Road Landfills E-MAILADDRESS <br /> OWNER HOME ADDRESS ATTENTION:ORCAREOF(OAT/ONAL) Don Litchfield <br /> CITY STATE zip <br /> OWNER MAILING ADDRESS 9999 S Austin Road <br /> MAILING ADDRESS CITY Manteca STATE CA ZIP 95336 <br /> ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ®RWQCB LEAD— ❑ 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 ANEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESSIFACILITY/SITEIPROJECTNAME Forward Landfill APN 201-060-010-000 <br /> SITE ADDRESS/PROJECT LOCATION 8610 Newcastle Road BUSINESSPHONE <br /> 209.235.9622 <br /> CITY Stockton STATE CA ZIP 95215 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENTFROM FACILITY ADDRESS 9999 S Austin Road <br /> MAILING ADDRESS CITY Manteca STATE CA ZIP 95336 <br /> SIC CODE COMMENT: <br /> REQUESTOR°S INFORMATION: <br /> BUSINESS NAME Arcadis US,Inc. ATTENTION Aaron Hook <br /> MAILING ADDRESS 735 Tank Farm Road,Suite 150 PHONE 805.242.0159 <br /> CITY San Luis Obispo STATE CA ZIP 93401 EMAIL aaron.hook@arcadis.com <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTORI_f <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Owner, Operator,Authorized Agent, <br /> or Responsible Part) and I acknowledge that all PERMIT FEES,PENALTIES,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 COUNTY 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 i ormation to S,,,�/�/�/NNN J QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pt ed o me or my rftpf' ative. <br /> APPLICANT NAME(PLEASE PRINT) Aaron Hook SIGNATURE <br /> TITLE Principal Scientist TAxID# <br /> FA#: 4 002C/� OWNER ID#: �1/l�/�tL/Y1� ACCOUNT#: �fi 0 774 <br /> ASSIGNED TO: <br /> PR#: /f/�n t-y I�T ACCOUNTING COMPLETED BY: l 1 (J '(,C•(J / DATE: g/? <br /> 7 3 <br /> SR TYPE PE / SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUESTd INVOICE# <br /> 3 903 5,-)3 -15 G 0 0 <br /> Site Mitigation MFR 2-26-2018 <br />