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SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />‘,10 tl1/404-1" <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"-GREEN FORM <br />m% D Or.74:611tr: 8 / 2018 0 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD E <br />PROPERTY <br />OWNER NAME <br />Ramesh Sood PHONE <br />510-828-2266 FIRST MI LAST <br />BUSINESS NAME A-ONE GAS & FOOD E-MAIL ADDRESS soodcorp@yahoo.com <br />OWNER HOME ADDRESS 7183 Fawn Hills Ln ATTENTION: ORCARE OF (OPWOAML) <br />CITY Pleasanton 94566 <br />STATE CA ZIP <br />OWNER MAILING ADDRESS 574 W. Grant Line Road <br />MAILING ADDRESS CITY Tracy STATE ( : A zip 95376 <br />2 CORPORATION In INDIVIDUAL 111 PARTNERSHIP ID GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />CI ENVIRONMENTAL . EHD LOCAL VOLUNTARY RWOCB LEAD- RWOCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (wDR) <br />2965 <br />E 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 /> <br />YES <br /> No a <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br /> <br />YES 2 N0LJ <br />BUSINEWMFACILWY/SITFJPROJECT NAME A-ONE GAS & FOOD AIM 233-030-010 <br /> <br />SITE ADDRESS / PROJECT LOCATION 574 W Grant Line Road <br /> BUSINESS PHONE 510-828-2266 <br />C'' Tracy <br />STATE CAZIP <br /> 95376 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 II Keil <br />MAILING ADDRESS , IF DIFFERENT FROM FACIUTY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br /> <br />BUSINESS NAME Fulcrum Resources Environmental <br /> <br />ATTENTION Don Kellar <br /> <br />MAILING ADDRESS 517 S. Ivy Avenue <br /> <br />PHONE 800-385-7105 <br /> <br />CITY Monrovia STATE CA ZIP 91016 EMAIL don@frenviro.com <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> OwNERD <br /> <br />FACILITY/BUSINESSE <br /> <br />REQUESTORQ <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 representative. <br />APPUCANT NAME (Pi PARE PRINT) Don Kellar SIGNATURE 5 :2- <br />TITLE Senior Geologist <br />FAS: <br />4 „. lif ASSIGNED TO: <br />- ACCOUNTING COMPLETED BY <br />. ./.6P <br />DATE: 12_ b /7 <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECD BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 Er' 451, fili& (.' X I "k i t k S F-0 0 -MS-9 <br />s-5-1,ssyc <br />Tax IDS <br />Site Mitigation MFR 2-26-2018