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STATE ZIP MAILING ADDRESS CITY <br />SIC CODE COMMENT: <br />BOARD OF SUPERVISOR DISTRICT 1 LOCATION CODE I ----K—E;1 1 I KEY2 1 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />SAN JO, IN COUNTY ENVIRONMENTAL HEALTH Di :TMENT <br />E MITIGATION MASTER FILE RECORD INFORMATION FORM REC'D MAY 15 2Ni; <br />"MFR"- GREEN FORM <br />DATE May 14, 2018 SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH END <br />PROPERTY <br />OWNER NAME <br />David Patten PHONE <br />925-842-7877 FIRST MI LAST <br />BUSINESS NAME <br />Chevron EMC <br />E-MAIL ADDRESS <br />drinttrnQrheunan crtni <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (0P770N.40 6001 Bollinger Canyon Road <br />City STATE LP San Ramon CA 94583 <br />OWNER MAILING ADDRESS <br />same as above <br />MAILING ADDRESS CITY STATE ZIP <br />D CORPORATION INDIVIDUAL El PARTNERSHIP <br /> El GOVERNMENT AGENCY LI RESPONSIBLE PARTY <br /> <br />CI OTHER <br />ENVIRONMENTAL 111 EHD LOCAL VOLUNTARY <br />-I <br /> RWQCB LEAD— <br />tiRRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WDR) <br />2965 <br />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? <br />Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES D No <br />YESO NOD <br />BUSINESS/FACILITY/SITE/PROJECT NAME Former Chevron 94054 APN 123-080-29 <br />SITE ADDRESS! PROJECT LOCATION <br />2103 Country Cleb Blvd. <br />BUSINESS PHONE <br />NA <br />Crry Stockton STATE ZIP <br />CA 95204 <br />REOUESTOR'S INFORMATION: <br /> <br />BUSINESS NAME GHD <br /> <br />ArrEnrnoN Ben Summersett <br /> <br />MAIUNG ADDRESS 4080 Goldorado Circle, Suite B <br /> <br />PHONE 9164365-0927 <br /> <br />Crry Cameron Park STATE CA ZIP 95682 EMAIL be n.summernettrI2g hd.com <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OINNERI=1 <br /> <br />FACILJTY/BUSINESSO <br /> <br />REQUESTORIX1 <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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable 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 />authorize 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 re resentative. <br />APPUCANT NAME (PLEASE PRINT) Ben Summersett SIGNATURE <br />TrtLE Scientist Tax ID # <br />r— <br />FA*: r--, OWNER ID*: ,— , ACCOUNT*: ASSIGNED TO: <br />PR it: ACCOUNTING COMPLETED BY: DATE: <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 <br />Site Mitigation MFR 2-26-2018