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SAN JOA,‘...)IN COUNTY ENVIRONMENTAL HEALTH DE. .RTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM REC <br />DATE 6/15/2018 <br />- ....a. <br />SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: IF 01INEDAL11204Y ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />JjENTAL HEAL r11 <br />209-2rAgt1X33 FIRST MI LAS- <br />BUSINESS NAME CITY OF MANTECA EMAIL ADDRESS HGROVE@CLMATECA.CA.US <br />OWNER HOME ADDRESS A TTENtioN: ORCARE OF (0P770N4L) <br />CITY MANTECA STATE CA ZIP 95337 <br />OWNER MAILING ADDRESS 2450W. YOSEMITE AVE <br />MAIUNG ADDRESS CITY Manteca STATE CA ZIP 95337 <br />CORPORATION <br /> CI INDIVIDUAL <br /> <br />DPARTNERSHIP :8] GOVERNMENT AGENCY <br /> <br />RESPONSIBLE PARTY <br /> <br />LI OTHER <br />II ENVIRONMENTAL . EHD LOCAL VOLUNTARY III RWQCB LEAD— 1. RWQCB LEAD— E DTSC LEAD <br />2959 <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />. FED EPA LEAD <br />2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br /> <br />YES E] <br /> <br />No E <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br /> <br />YES E <br /> <br />No IZ <br />BUSINESS/FACILITY/SITE/PROJECT NAME GREAT WOLF LODGE APN: 24131053 <br /> <br />SITE ADDRESS! PROJECT LOCATION: 2600W Yosemite Ave BUSINESS PHONE 209-456-8000 <br />Crn, MairrEc4 <br /> <br />STATE ZIP 95337 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Ker1 Ker2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS 101 W CENTER Sr <br />MAILING ADDRESS CITY MANTECE <br /> <br />STATE ZIP 95337 <br />CA <br />SIC CODE <br /> COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME GREAT WOLF LODGE ATTENTION: ORCARE OF (OP77ON4L) <br />MAILING ADDRESS 350 N ORLEANS ST, SUITE 10000E3 PHONE <br />CITY CHICAGO STATE IL ZIP <br />I ACCOUNT AGGRESS To SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSO THIRD PARTY BILLING/81 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 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 nrovided to me or my renresentative. <br />APPUCANT NAME (PLEASE PRINT) MEGAN MURPHY SIGNATURE <br /> <br />`1( <br />TrTLE STAFF GEOLOGIST <br /> <br />TAX ID* <br /> <br />FA #: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD 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 29- XXX 8-1-2017