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T <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE <br />101/05/2022 <br />1 <br />SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />CHECKwOwNER/B CURRENn YONf/LEwnN EHD <br />PROPERTY <br />OWNER NAME <br />CLEANUP <br />CORRECTIVE ACTION <br />PHONE <br />FIRST ST <br />2954 <br />BUSINESSNAME CITY OF LODI - responsible party <br />2953 <br />E-MAILADDRESS arichle@lodi.gov <br />OWNER HOME ADDRESS ATTENTIOWORCAREOF(OPTIONAL) ANDREW RICHLE <br />CITY LODI STATE CA ZIP 95240 <br />OWNER MAILING ADDRESS 1331 SOUTH HAM LANE <br />zip <br />MAILING ADDRESS CITY LODI <br />STATE CA ZIP 95242 <br />❑ CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ GOVERNMENT AGENCY ® RESPONSIBLE PARTY ® OTHER <br />ENVIRONMENTAL <br />❑ EHD LOCAL VOLUNTARY <br />® RWQCB LEAD- <br />❑ RWQCB LEAD- <br />❑ DTSC LEAD <br />❑ FED EPA LEAD <br />ASSESSMENT <br />CLEANUP <br />CORRECTIVE ACTION <br />WATER QUALITY (WDR) <br />2959 <br />2954 <br />2950 <br />2953 <br />296013526/3527 <br />2965 <br />STATE <br />zip <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ <br />IS THIS AN EXISTING PROJECT LOCATION, BUT ANEW SCOPE OF WORK? YES ® <br />No <br />No ❑ <br />BUSINESSIFACILITY/Sn7EWROJECTNAME Lodi Southern Plume (LSP) Soil Vapor Sampling <br />APN <br />04530032 <br />SITE ADDRESS I PROJECT LOCATION 1345 S. Sacramento Street <br />BUSINESSPHONE <br />CITY LODI <br />STATE CA ZIP 95240 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS <br />KEY2 <br />2903 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />$456.00 <br />456+228 <br />MAILING ADDRESS CITY <br />STATE <br />zip <br />SIC CODE <br />COMMFNr: <br />2904 <br />REQUESTOR'S INFORMATION: <br />BUSINESS NAME CIVIL HYDRO TECH, LLC ATTENTION VARINDER OBEROI <br />MAIDNGADDRESS 175 N. EL MONTE AVENUE PHONE 415-424-3009 <br />CITY LOS ALTOS STATE CA ZIP 94022 EMAIL varinderoberoi@comcast.net <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTORM <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 ffly representative. <br />APPLICANT NAME (PLEASE PRINT) VARINDER OBEROI SIGNATURE <br />TITLE PRESIDENT TAxID* 82-4411876 11 <br />FA 9: FA0026941 II OWNER ID#: ow0025589 <br />PR 9: PR00547395 JFACC.UNTING COMPLETED BY: <br />ACCOUNT#: AR0051517 II ASSIGNEDTO: JW <br />DATE: <br />SR TYPE <br />PE <br />Sc <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />SERVICE REQUEST# <br />INVOICE# <br />Work Plan <br />2903 <br />523 <br />$456.00 <br />456+228 <br />cc <br />JW <br />1/6/2022 <br />SR0084701 <br />2904 <br />523 <br />$760.00 <br />confirmation number: 136936315, 136986167 <br />Site Mitigation MFR 2-26-2018 <br />