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SAN JOAL(UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 11/1/2018 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Bonny Carter PHONE 209.830.3200 <br />FIRST MI LAST <br />BUSINESS NAME Tracey Unified School District E-MAIL ADDRESS bcarter@tusd.net <br />OWNER HOME ADDRESS ATTENTION: CNiCARE OF (0P770NAL) <br />Orr STATE ZIP <br />OWNER MAILING ADDRESS 1875 West Lowell Ave <br />MAILING ADDRESS CITY Tracy STATE CA ZIP 95376 <br />111 CORPORATION <br /> <br />INDIVIDUAL <br /> <br />PARTNERSHIP <br /> 1=1 GOVERNMENT AGENCY D RESPONSIBLE PARTY <br /> E OTHER <br />ENVIRONMENTAL M EHD LOCAL VOLUNTARY RWQCB LEAD — <br />INIRRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WDR) <br />2965 <br />. DISC LEAD E FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No N <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF wonN? YES 0 No 2,1 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Delta Island School APN <br />SITE ADDRESS / PROJECT LOCATION 11022 Howard Rd BUSINESS PHONE <br />CITY Stockton STATE CA ZIP 95206 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil Ker2 <br />MAIUNG ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE CommENT: <br />REGUESTOR'S INFORMATION: <br />BUSINESS NAME GHD Services. Inc ATTENTION Nathan Diem <br />2300 ADDRESS 2300 Clayton Road Suite 920 HONE PHONE <br />510.292.7879 <br />CITY Concord STATE CA ZIP 94520 EMAIL Nathan.Diem@ghd.com <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNERE <br /> <br />FACILITYIBUSINESSE <br /> <br />REQUESTORE <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party 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 information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) Nathan Diem <br />TITLE <br />Project Geologist <br />SIGNATURE <br />TAx loot <br />FA II: -,--A <br />//4 11)92 3 5-2 c C OWNER ID MD 14161/ 8,6 Z, ACCOUNT:1:M 4i.3.y 1 ,g, ASSIGNED TO: <br />PR Si: Aagi4 i 0 zg.- ACCOUNTING COMPLETED eY: DATE: <br />ii <br /> Lif . <br />A <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REMIT BY DATE SERVICE REQUEST. INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 .2A03 4-1165V-- k —I / til -r-h% sPio -rryz_s.; <br />Site Mitigation MFR 2-26-2018