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SAN puAQUIN COUNTY ENVIRONMENTAL HEALTH Dt,ARTMENT DATE 5/21/2013 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHEcKIFOwNERisCuRRENTLvoNFILEWITH EH PROPERTY OWNER NAME Gary Dobler (209) 482-2275 FIRST MI LAST PHONE NUMBER BUSINESS NAME E-MAILADORESS OWNER HOME ADDRESS 276 W.20th Street CITY Tracy STATE ZIP CA 95376 OWNER MAILING ADDRESS Same as home address MAILING ADDRESS CITY STATE ZIP ❑CORPORATION ®INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION LOP_ FACILITY ID# INV# ACCOUNTID PR#IRO# ASSIGNED EMPLOYEE LEADAGENcY:EHD_RWQCB_DTSC_EPA_ Jo�41uu FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 91 IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ® No ❑ BUSINESSIFAciuTYISITEIPROJECTNAME Chevron Environmental Management Company(CEMC)/Former Tracy Pump Station SITE ADDRESS I PROJECT LOCATION 14821 W. Grant Line Road SUITE# BUSINESS PHONE 925-790-6431 CITY Tracy STATE CA ZIP 95304 BOARD OF SUPERVISOR DISTRICT LOCATION CODE 3 KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) 6101 Bollinger Canyon Road,Room 5384 Michael Oliphant MAILING ADDRESS C1STATE Ramon STATE ZIP CA 94583 SIC CODE 7 APN#2O(j_IQ Q `O COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME SAIC Energy,Environment,and Infrastructure,LLC ATTENTION:ORCAREOF(OPTIONAL) Sean Gehlke MAILING ADDRESS 1000 Broadway,Suite 675 PHONE 510-466-7148 CITY Oakland STATE CA ZIP 94607 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Omaer,Operator,Authorized Agent,or Revpouvib/e Parte and I acknowledge that all PERIDT FEES, PEA.4LTIE.S,ENFORCEAtEATCNARGES and/or 11ouRLY CN.4RGES associated with this project will be billed to me at the address identified above as the A CCODA7aDDRESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Lancs and REGULATIONS. As the undersigned(honer,Operator,authorized Agent,or Ropnnvible Parte for the project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COIATY ENVIRONMENTAL HEALTu DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Sean Gehlke SIGNATURE TITLE SAIC Project Geologist TAX ID# 20-1659855 APPROVED BY I DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WOE(PLAN PPE FEE: