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RECEIVED <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DEC 113 2018 <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM ENVIRONMENTAL HEALTH <br />DATE 11) Willi') VEL::131k R EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON ALE WITH EHD fl <br />PROPERTY <br />OWNER NAME <br />Cory J Davis PHONE <br />714.909.5066 FiRsr MI LAST <br />13"1"E"AalE Arcadis Ewa m Amon <br />cory.davisParcadis corn <br />°mot H°ME Af"S 320 Commerce, Suite 200 ATTENTION: ORCARE Or (anima) <br />c"Y Irvine STATE CA z"' 92602 <br />°MIER PAAILMG ADDRESS 320 Commerce, Suite 200 <br />MARINO ADDRESS CITY Irvine STATE CA zw 92602 <br />0 CORPORATION 0 berm& 0 PARTNERSHIP CI GOVERNMENT AGENCY IE ResPoNsome PARTY 0 Oniea <br />III ENVIRONMENTAL IN EHD LOCAL VOLUNTARY ErRWQCB LEAD - <br />COFIRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (MR) <br />2965 <br />DISC LEAD FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! BITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No IXI <br />IS THIS AN sotrivio PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES IA No El <br />BuemselFaclurdftsiw"c"w:c71""wE Well Destruction Activities APN 21449003 <br />8rmAD0RE1181PRWECT 14CM1°" 575 W Grant Line Road Busmen PHONE <br />CITY STATE Tracy CA ZIP 95376 <br />BOARD OP SUPERVISOR DISTRICT I ILoot Cooe I Kevi II Key2 1 <br />MALIN° "emu ."1"ealENTRicsi FAclunAmese 320 Commerce, Suite 200 <br />MmuNce ADDRESS CITY Irvine <br />STATE CA ZIP 92602 <br />SIC CODE Comma: <br />HEQUESTOR'S INFORMATION.: <br />Busmen MANE Arcadis ATTENTAM Cory Davis <br />"u"A"*"""" 320 Commerce, Suite 200 P"c** 714.909.5066 <br />CITY Irvine STATE CA VP 92602 BAWL cory.davis@arcadis.com <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br />IOWNER0 FACILITY/BUSINESS:I HEQUESTORN 'I <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 locat <br />authorize the release of any and all results, reports, and other environmental ass <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pr <br />APPUOANT NUE (PLEASE NKr) Cory Davis <br />TITLE <br />Environmental Scientist <br />BONA <br />ove under faci le address, I hereby <br />' formati to SAN OAQUIN COUNTY <br />thy represe tative. <br />PAS: ritoos—col, amen m #: Otax,34.7y_ Iimam* A/2_601.71642ro ASSIGNED TO: <br />" 5: rideD13 ACCOUNTING compLErm cm DATE /2lig <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECKS RECVD BY DATE SERVICE REQUESTS INVOICES <br />Work Plan 2903 <br />2904 <br />523 <br />623 <br />$456.00 <br />$760.00 <br />1, <br />1 q 5' Ifiloti- L -* 1 1_1•Itg S(L.0 0(6.000C <br />Site Mitigation MFR 2-26-2018