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SAN QUIN COUNTY ENVIRONMENTAL I-IEALTI-, PARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE 3/14/2015 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ONFnewirH EHD PROPERTY PHONE OWNER NAME I FIRST Ml LAST 530-673-6770 BUSINESS NAME E-MAIL ADDRESS John Taylor Fertilizer EJenks@Wilburellis.com OWNER HOME ADDRESS ATTENTION:OR CARE OF(OPTIONAL) Eric Jenks CITY STATE zip OWNER MAILING ADDRESS PO Box 511 MAILING ADDRESS CITY Yuba City STATE CA ZIP 95991 ®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 ❑ BUSINESSIFACILITY/SITE/PROJECTNAME Former John Tayler Fertilizers Co.facility APN: 163-200-008 SITE ADDRESS/PROJECT LOCATION 1819 S.Argonaut St. BUSINESS PHONE CITE' Stockton STATE CA ZIP 95206 BOAR. SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Geosyntec Consultants, Inc. ATTENTION:ORCARE OF (OP77ONAL) Pete Dennehy MAILING ADDRESS 3043 Gold Canal Dr.#100 PHONE (916)637-8341 CITY Rancho Cordova STATE CA zip 95670 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTYBILLINGIN BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent, 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 ACCOUNTADDRESS 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 JOAQ['IN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Pete Dennehy SIGNATURE L I,reL•^ TITLE Hydrogeologist-Geosyntec Consultants, Inc. TAX ID# 59-2355134 FA#:1:i'Aj��, 1 � OWNER ID#:� ) / ACCOUNT#;{I /„ / ASSIGNED T0: PR#:-1 6 -O v3, ACCOUNTING COMPLETED BY: ` (P ' 4 !v`f DATE: 9-3-2015 Site Mitigation MFR 29-