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SAN J RUIN COUNTY ENVIRONMENTAL HEALTH ARTMENT DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM 11 03/06/13 n SITE MITIGATION & LOP SIIADEn Same FDR END USE ONLY OWNER IDs CAUSE SRU0GG9G8 UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CmwKArOmERisOuaaeRnrGov rHEwirHEHD � PROPERTYOWNERNANE Katy I I Laubach ( ) (408)912-2287 FIRST MI LAST PHONE NUMBER BUSINESS NAME Wildcat Metals-Carnegie LLC EAWULADDRESS OWNERHome ADORESS 890 Fa'�ulstich Court CITY San Jose, CA STATE zip CA 95112 OWNER MAILING ADDRESS MAILING ADDRESS CITY STATE ZIP 93(CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION X ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP FACILITY ID# INv# Accouxr lD FIR#1 RO# ASSIGNED EMPLOYEE I LEAD AGENCY:EHD=RWQCB_DTSC XX EPA_ FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 50 IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES;['] No ❑ BUSINESSIPACILITY/SnEJPRQIECTNAME Commercial Property - monitoring well destructions StrEADDRESS/PROJEOTLOCWfON 555 Carnegie Way SUITE# BUSINESS PHONE 408-912-2287 CITY Manteca (� STATECA 7JP 953375 BOARDOFSUPERWSORDMTRICT S LOCATION CODE I KI KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPROHAL) MAIUNG ADDRESS CRY STATE LP SICCODE APN#Q�I-��ro-bH COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Advanced Geo Environmental Inc. ATTENTION:GROANS OF(OTAOAAL) MAIUWADORM 837 Shaw Road PHONE 209-467-1006 Om Stockton STATE CA zip 95215 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERO FACILITY/BUSINESS❑ THIRD PARTY BILLINGA BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned Applicant,certify that I am the(Avner,Operator,Authorized Agent,or Responsible Party and I s elmmudedge that all P£RA117 FEES, PENAzim,ENFORCEMENT CHARrE.S and/or HOURLY CHARGE.s'associated with this project will be billed tome at the address identified above as the ACC'OHNTADDRESS 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 JOAQVIN COUNTY ORDINANCE CODES newer STANDARDS and STATE and/or FEDERAL Laws and REGUunONS. As the undersigned(honer,Operator,Authorized Agent,or Responsible Parry for the project located above under fadGty/site address,I hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPUCANTNAME(PLEASEPRINT) William Little SIGNATURE �)( TME Geologist TA ID# APPROVm BY DATE AODOUNDNA OFFICE PROCESMNG COMPLETE[)13Y DAIS SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHEON# RECEIVED BY WO'B/K PUN PE FEE:;