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SAN k QUIN COUNTY ENVIRONMENTAL HEALTF .PARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 04/19/2017 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 />LEVAND FAMILY TRUST & Paula Levand - Trustee PHONE <br />(661) 904-2133 LEVAND BRIGHTsFAMILY TRUST it4/ Joan Konkcl Tmstcc <br />BUSINESS NAME <br />Levand-Bright Property <br />E-MAIL ADDRESS <br />plevand@mac.com <br />OWNER HOME ADDRESS 24692 Sand Wedge Lane ATTENTION: ORCARE OF (0P770NAL) <br />CITY STATE ZIP Valencia CA 91355 <br />OWNER MAILING ADDRESS Same as above <br />MAILING ADDRESS CITI STATE ZIP <br />El CORPORATION <br /> <br />El INDIVIDUAL <br /> 0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY L RESPONSIBLE PARTY <br /> <br />0 OTHER <br />E ENVIRONMENTAL E EHD LOCAL VOLUNTARY e RWQCB LEAD— M RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />M DTSC LEAD M 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 El No KI <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES [il No 111 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Levand-Bright Property APN: <br />233-369-18 <br />SITE ADDRESS! PROJECT LOCATION 3 East 11th Street BUSINESS PHONE <br />(661) 904-2133 <br />Cm, Tracy STATE ZIP CA 95376 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keel KEr2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />24692 Sand Wedge Lane <br />MAILING ADDRESS err( Valencia STATE ZIP CA 91355 <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> <br />BUSINESS NAME Advanced GeoEnvironmental, Inc. ATTENTION: ORCARE OF (OPTIONAL) <br /> <br />MAILING ADDRESS <br />837 Shaw Road <br /> PHONE <br /> <br />Crry <br />Stockton <br /> STATE C A ZIP 95215 <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNEREI <br /> <br />FACILITYIBUSINESSEI <br /> <br />THIRD PARTY BILLINGI21 <br /> <br />BILLING AND CONIPLIANCE ACKNOWLEDGMENT: I, 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 information <br />provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br />JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br />Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br />release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTII DEPARTMENT as soon as it is available and at the same time it is provided to me or my repesentative. <br />APPLICANT NAME (PLEASE PRINT) Brian Millman <br /> <br />SIGNATURE <br /> <br />TITLE Project Geologist <br /> <br />TAX ID # <br /> <br />FA #: OWNER ID #: C) /OD 2 22+3 1 ACCOUNT #: Apz04+57 ..2_ ASSIGNED TO: <br />PR $: ACCOUNTING COMPLETED BY: DATE: <br /> <br />9-3-2015 <br />Site Mitigation MFR 29-