Laserfiche WebLink
SITE MITIGATION MASTER FILE RECORD INFORMATION FO <br />SAN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />"MFR"- GREEN FORM <br />DATE 8/9/2017 <br />rLu 'J <br />F6'f li") PHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK I OWNER A At F SIECINBANWATIAthrtlika <br />PERMIPSERVTCES PHONE <br />(650)632-4522 <br />PROPERTY <br />OWNER NAME FIRST MI LAST <br />BUSINESS NAME Saybrook CLSP, LLC E-MAIL ADDRESS <br /> jwilson@saybrookfundadvisors.com <br />(opr/oN,40 <br />Saybrook Fund Advisors, LLC OWNER HOME ADDRESS 303 Twin Dolphin Drive, Suite 600 ATTENTION: OR CARE OF <br />CITY Redwood Shores STATE CA ZIP 94065 <br />OWNER MAILING ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />D CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY D RESPONSIBLE PARTY El OTHER <br />III ENVIRONMENTAL EHD LOCAL VOLUNTARY RWCICB LEAD- G: RWQCB LEAD - <br />II DTSC LEAD <br />2959 ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />FED EPA LEAD <br />2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES 0 No n <br />YES Ed No 0 <br />BUSINESSIFACILITY/SITE/PROJECT NAME Consolidated Treatment Facility, Central Lathrop Specific Plan area APN: 191-210-08/191-220-13 <br />SITE ADDRESS / PROJECT LOCATION Golden Valley Parkway/De Lima Road <br />BUSINESS PHONE <br />CITY Lathrop STATE CA ZIP 95330 <br />BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I I KEY1 I I KEY2 I <br />MAILING ADDRESS ,IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME HydroFocus, Inc. ATTENTION: ORCARE OF (OPTIONAL) <br />MAILING ADDRESS P.O. Box 2401 PHONE (530)759-2484 <br />CITY Davis STATE ZIP CA 95617 <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> OWNERD <br /> <br />FACILITY/BUSINESS:I <br /> <br />THIRD PARTY BILLING( <br /> <br />BILLING AND COMPLIANCE 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 />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or 1nye resent e. <br />SIGNATUREc. <br />. <br />_ <br />TITLE President, HydroFocus, Inc. <br /> Tax ID# <br /> <br /> <br />F " : rA 00e2--4fi / ee, <br />OWNER ID if: )1.4.)60 7272z-- ACCOUNT #: A R.Doi] q qz- ASSIGNED TO: <br />PR #: ?kos-zfaii x-- ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHEW RECV'D BY DATE SERVICE REQUEST INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 <br />I ,,J .,-I <br />I sc 811. It j s -r A"001isb&O <br />Site Mitigation MFR 29- XXX 8-1-2017 <br />APPLICANT NAME (PLEASE PRINT) v'ejç J- De.