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CITY WEST SACRAMENTO STATE CA ZIP 95691 <br />THIRD PARTY BILLING)Ell ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESS0 <br />ATTENTION: ORCARE OF (OPTIONAL) BUSINESS NAME WALLACE-KUHL & ASSOCIATES <br />MAILING ADDRESS 3050 INDUSTRIAL BOULEVARD PHONE 916-372-1434 <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />FA #: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: <br />SAN JOAC" "N COUNTY ENVIRONMENTAL HEALTH DED 1kRTMENT <br />SITE MITIGA iN MASTER FILE RECORD INFORN. ION FORM <br />"MFR"- GREEN FORM <br />DATE I 8-6-18 SHADED AREAS FOR END 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 />PHONE <br />209-832-7000 FIRST MI LAST <br />BUSINESS NAME SURLAND COMMUNITIES, LLC E-MAIL ADDRESS CHRIS@SURLAND.EMAIL <br />OWNER HOME ADDRESS ATTENTION: OR CARE OF (OPTIONAL) <br />CITY <br /> <br />STATE CA <br /> <br />ZIP <br />OWNER MAILING ADDRESS 1024 CENTRAL AVENUE <br />MAILING ADDRESS CITY <br /> Tracy STATE CA <br /> <br />ZIP 95376 <br />EICORPORATION <br /> 0 INDIVIDUAL 1:1 PARTNERSHIP <br /> I=1 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> 0 OTHER <br />;SI ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />. EHD LOCAL VOLUNTARY II RWQCB LEAD — 111 RWQCB LEAD — <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />M DTSC 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? YES <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES <br />3E( No El <br />No )iZ <br />BUSINESS/FACILITY/SITE/PROJECT NAME ELLIS SUBDIVISION APN: 240-140-450 <br />SITE ADDRESS / PROJECT LOCATION NORTH SIDE OF SITE IS APPROX. 4,010 FEET S/O VALPICO ROAD EXTENDING TO APPROX. 5,100 <br />FEET S/O VALPICIO ROAD & APPROXIMATELY 2,700 FEET W/O CORRAL HOLLOW ROAD & EXTENDING TO APPROXIMATELY 5,025 FEET W/O <br />CORRAL HOLLOW ROAD. <br />BUSINESS PHONE 209-832-7000 <br />CITY TRACY STATE ZIP 95377 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <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 />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 my representative. <br />APPLICANT NAME (PLEASE PRINT) f 4- /4-11) /W4. //Ace • K vI4) .4' 5 4 +-') SIGNATURE _ <br />TITLE r c,j sr <br /> AA vs. <br />9-3-2015Site Mitigation MFR 29- XXX 10-26-2015