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CITY Oakland STATE CA ZIP 94612 <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERO FACIUTY/BUSINESSE THIRD PARTY BILLING <br />MAILING ADDRESS 501 14th Street, 3rd Floor PHONE 415-955-5277 <br />BUSINESS NAME Langan Engineering and Environmental ATTENTION: ORCARE Varinder Oberoi Go Noel Liner <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 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 />City of Lodi PHONE (209) 333-6706 <br />FIRST MI LAST <br />BUSINESS NAME City of Lodi E-MAIL ADDRESS <br />OWNER NOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL) <br />CITY STATE ZIP <br />OWNER MAILING ADDRESS 221 W Pine St. <br />MAILING ADDRESS CITY Lodi STATE CA ZIP 95240 <br />0 CORPORATION <br /> 0 INDIVIDUAL El PARTNERSHIP <br /> XI GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> 0 OTHER <br />E ENVIRONMENTAL EHD LOCAL VOLUNTARY Pi RWQCB LEAD- RWQCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />296013526/3527 <br />WATER QUAUTY (NDR) <br />2965 <br />DISC LEAD 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? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES 0 No E <br />YES 2 No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Mid-Plume Replacement Extraction Well APN: APN number not assigned <br />SITE ADDRESS / PROJECT LOCATION 531 Church St BUSINESS PHONE (209) 333-6706 <br />Cm( Lodi STATE CA ZIP 95240 <br />BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I I KEY1 I I KEy2 I <br />MAILING ADDRESS , IE DIFFERENT FROM FACILITY ADDRESS 221 W Pine St. <br />MAILING ADDRESS CITY Lodi STATE CA Zip 95240 <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO' COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <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 JoAQULN 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 />APPLICANT NAME (PLEASE PRINT) \lf\O_i41 occS. OQEeo SIGNATURE <br />TAX ID* TITLE SE t,soK CTlAi\O\CAEc <br />FA #: ,--ASSIGNED OWNER ID #:,;.)146022245__ ACCOUNT #: 42[0(.1403 TO: <br />PR #: :pets-4/16 a 4. <br />as) <br />ACCOUNTING COMPLETED BY: DATE: ..2/ 0/7 <br />9-3-2015 <br />Site Mitigation MFR 29-