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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 2/21/2024 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNERIS CURRENTLYONFILE WITH EHD <br /> PROPERTY UPRR - PHONE <br /> OWNER NAME FIRST MI LAST <br /> BUSINESSNAME Union Pacific Railroad Company E-MAIL ADDRESS <br /> OWNER HOME ADDRESS 1400 Douglas Street ATTENTION:ORCARE OF(OPTIONAL) <br /> CITY Omaha STATE NE ZIP 68179 <br /> OWNER MAILING ADDRESS 1400 Douglas Street <br /> MAILING ADDRESS CRY Omaha STATE NE ZIP 68179 <br /> ©CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY 0 RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No x❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No ❑x <br /> BUSINESSIFACILm/SnFJPROJECTNAME Union Pacific Railroad Yard,Tracy APN 235-15-002 <br /> SITE ADDRESS/PROJECT LOCATION Near the intersection Of4th St.and N.Central Ave. BUSINESS PHONE <br /> CITY Tracy STATE CA ZIP 95376 <br /> r <br /> L BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS NA <br /> MAILING ADDRESS CITY NA STATE ZIP <br /> SIC CODE COMMENT: <br /> REQUESTOR'S INFORMATION: <br /> BUSINESS NAME Antea Group ATTENTION <br /> MAILINGADDRESS 1101 White Rock Rd. STE 140 PHONE <br /> 737-279-9848 <br /> CITY Rancho Cordova pp• @antea rou STATE CA ki sande ZIP 95670 EMAIL us <br /> 9 p• <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR® <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 /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE TAX ID# <br /> FA#: OWNER ID M ACCOUNT M ASSIGNED TO: <br /> PR#: ACCOUNTING COMPLETED BY: DATE: <br /> ESRYP,E PE SC FEEINFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> 2903 523 $486.00 <br /> 2904 523 $810.00 <br /> Site Mitigation MFR 7-01-2023 <br />