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ATTENTION: ORCARE OF (01,770N4LL gect <br />PHONE <br />916.786.7369 <br />SIGNATURE 0/ <br />TAX ID# <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />AUG 2 3 RECO <br />DATE <br />SHADED AREAS FOR EHD USE August 10, 2017 <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILEN/777i EHD <br />PROPERTY <br />PHONE <br />OWNER NAME FIRST MI LAST <br />BUSINESS NAME <br />Glenn Springs Holdings Inc <br />OWNER HOME ADDRESS 5 Greenway Plaza, Suite 110 <br />crrY Houston <br />OWNER MAILING ADDRESS Same as above <br />E-MAIL <br />ADDRESS Roger_Smith@OXY.com <br />ATTENTION: ORCARE OF (OPTIONAL) Roger Smith <br />STATE TX <br /> <br />ZIR 77046 <br />MAILING ADDRESS CITY <br />STATE ZIP <br />I=1 CORPORATION El INDIVIDUAL El PARTNERSHIP 0 GOVERNMENT AGENCY In RESPONSIBLE PARTY 0 OTHER <br />111 ENVIRONMENTAL Il END LOCAL voLuNTARy <br />CLEANUP <br />2953 <br />12. RWQCB LEAD- <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />WATER QUALITY (VVDR) <br />2965 <br />. DISC LEAD M FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS /SIT _ . _..._....._.... <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 rA <br />YES W NO D <br />BUSINESS/FACILTIWSITFJPROJECT NAME <br />Former OCC Lathrop Facility APN: <br />SiTE ADDRESS / PROJECT LOCATION 16777 Howland Road BUSINESS PHONE <br />CITY <br />Lathrop STATE ZIP CA 95330 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keel 1 KEy2 <br />WWII() ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />Arcadis U.S Inc: 101 Creekside Ridge Court, Suite 200 <br />MAILING ADDRESS CT' <br />Roseville. Ca STATE 95678 <br /> <br />[0 000€ COMMENT: <br /> <br />- - _ <br />ILLING INFO: OMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME Arcadis U.S Inc <br />MAIUNG ADDRESS 101 Creekside Ridge Court, Suite 200 <br />CITY Roseville, STATE CA <br /> ZiP 95678 <br />I ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br />OWNER0 <br /> <br />FACILITY/BUSINESS:I <br /> <br />THIRD PARTY BILLING@ <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: 11., the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, 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 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 my representative. <br />APPUCANT NAME (PLEASE PRINT) 3----en t .1' g 6-) CAka-4)I •S ) <br />Marla cj or 7 AU 1-; 61 6 <br />TITLE <br />I ACCOUNT #: <br />FA 0: r' OWNER ID #: n022:---65- ASSIGNED TO: <br />PR s: pRoz.4.34.1? ACCOUNTING COMPLETED BY: a7Z2- DATE: <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />2903 <br />2904 Work Plan I/ <br />523 <br />523 <br />$456.00 <br />$760 00 s 6 7),,z/rs, - <br />„ <br />crif7 .7 00 7 (/ .0 <br />Site Mitigation MFR 29- XXX 8-1-2017