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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE SHADED AREAS FOR EHD 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 />c ry J Davis PHONE <br />714.909.5066 FIRST MI LAST <br />BUSINESS NAME Arcadis E-MAIL ADDRESS <br />cory.davisl@arcadis.com <br />OWNER HOME ADDRESS 320 Commerce, Suite 200 ATTENTION: ORCARE OF (OP770AIAL) <br />cm Irvine STATE CA z"' 92602 <br />OWNER MAILING ADDRESS 320 Commerce, Suite 200 <br />MAIUNG ADDRESS CITY Irvine STATE CA ZIP 92602 <br />0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY IX RESPONSIBLE PARTY 0 OTHER <br />. ENVIRONMENTAL M EHD LOCAL VOLUNTARY . RWQCB LEAD— RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUAUTY (WDR) <br />2965 <br />DISC LEAD 1. 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 DEPARTP•1EN1? YES <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES <br />0 No IX <br />21 No 0 <br />BUSINESINFACILITY/SITMPROJECT NAME Well Destruction Activities APN 21449003 <br />SITE ADDRESS !PROJECT LOCATION 575 W Grant Line Road BUSINESS PHONE <br />CITY STATE Tracy . ZIP CA 95376 <br />BOARD OF SUPERVISOR DISTRICT 1 I LOCATION CODE I I Ken 1 1 [Kea I <br />MAIUNG AODRESS , IF DIFFERENT FROM FACILITY ADDRESS 320 Cornmerce, Suite 200 <br />MAIUNG ADDRESS CITY Irvine STATE ZIP CA 92602 <br />SIC CODE Cowen.: <br />REOUESTOR'S INFORMATION: <br />BUSINESS NAME Arcadis "rem)" Cory Davis <br />MAILJNO ADDRESS 320 Commerce, Suite 200 PHONE 714.909.5066 <br />CDT Irvine STATE CA ZIP 92602 EMAIL cory.davis@arcadis.com <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br />IOWNE <br />RD FACILITY/BUSINESS!: REOUESTOREI <br />. I <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, 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 />APPLICANT NAME (PLEASE PRINT) Cory Davis SIGMA <br />ove under faci <br />ent formatis to SAN <br />thy represe <br />te address, I hereby <br />OAQUIN COUNTY <br />tative. <br />TITLE <br />Environmental Scientist <br />FA N: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR /*: 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