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BUSINESS NAME GHD ATTENTION Ben Summersett <br />MAILING ADDRESS 943 Reserve Drive PHONE 916-865-0927 <br />ZIP 95678 EMAIL ben.summersettraghd.com Cm( <br />Roseville STATE CA <br />SAN JOAk4u1N COUNTY ENVIRONMENTAL HEALTH DEP,-„TMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE October 15, 2018 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 />James Kiernan <br />PHONE <br />925-842-3220 FIRST MI LAST <br />BUSINESS NAME <br />Chevron EMC <br />E-MAIL ADDRESS <br />jklernanUch”vron rorn <br />OWNER HOME ADDRESS <br />6001 Bollinger Canyon Road <br />ATTENTION: OR CARE OF (OPTIONAL) <br />CITY <br />San Ramon <br />STATE ZIP <br />CA 94583 <br />OWNER MAILING ADDRESS <br />same as above <br />MAILING ADDRESS CITY STATE ZIP <br />CI CORPORATION El INDIVIDUAL El PARTNERSHIP 0 GOVERNMENT AGENCY CI RESPONSIBLE PARTY CI OTHER <br />CI ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />LII EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />111 RWQCB LEAD- <br />WATER QUALITY (WDR) <br />2965 <br />LI DISC LEAD <br />2959 <br />CI 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? YES LI No 111 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No LI <br />BUSINESS/FACILITWSITE/PROJECT NAME <br />Former Chevron 94054 <br />APN 123-080-29 <br />SITE ADDRESS / PROJECT LOCATION BUSINESS PHONE <br />2103 Country Club Blvd. NA <br />Ore Stockton STATE <br />CA <br />ZIP <br />95204 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kul Kea I <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />EQUESTOR'S INFORMATION <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OVVNERD FAcILITY/BUSINESSO REQUESTORa <br />BILLING AND CONIPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />7r 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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />tpplicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br />undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />tuthorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL 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) <br /> Ben Summersett <br />SIGNATURE <br /> - <br />TITLE <br /> Scientist <br />TAX 10# <br /> <br />FA #: r4 Iss, OWNER ID #: <br />0 ilkj.3.01 <br />ACCOUNT #: /41 (1)(4, 7 3. / ASSIGNED TO: <br />PR IF: ?k,os_e43 s.s-1_, ACCOUNTING COMPLETED BY: (Ai DATE: / ZYZIOF <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 , v51 iki; _> tiL-Liis% i c I 1 ii.... <br />Site Mitigation MFR 2-26-2018