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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHEoxIFOmvERisCURmwmYONRLEwfl/EHD <br /> PROPERTY Harshad and Gira Patel and Patel PHONE <br /> OWNER NAME t-IRST M1 LAST <br /> BUSINESS NAME ARP Minimart Corporation E-MAILADDRESS <br /> OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPT70NAL) <br /> CRY STATE ZIP <br /> OWNER MAILING ADDRESS 25775 South Patterson Pass <br /> MAIUNADDRESSCm Tracy STATE CA ZIP 95377 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ®OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ® RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WEIR) 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 <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESSIFACIuRY/SnWISROJECTNAME Former Atlantic Richfield Company(ARCO)facility No.6100 APN 209-100-040-000 <br /> SITE ADDRESS I PROJECT LOCATION 25775 South Patterson Pass BUSINESSPHONE <br /> CITY Tracy STATE CA ZIP 95377 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEH KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAI UNG ADDRESS CITY STATE ZIP <br /> SIC CODE COMMENT: <br /> REQUESTOR'S INFORMATION: <br /> BUSINEssNAME Arcadis ATTENTION Sherrie Lang <br /> MAILING ADDRESS 101 Creekside Ridge Court,Suite 200 PHONE <br /> CITY Roseville STATE CA ZIP 95678 EMAIL Sherrie.Lang@arcadis.com <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOREI <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 mP nr my representative. <br /> APPLICANT NAME(PLEASE PRINT) Sherrie Lang SIGNATURE <br /> TITLE Associate Project Manager TAX100 57-0373224 <br /> FA C OWNER ID#: I ACCOUNT#: ASSIGNED TO: <br /> PR#: ACCOUNTING COMPLETED BY: DATE: <br /> ESRE' PE SC FEEINFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> 2903 523 $456.00 <br /> 2904 523 $760.00 <br /> Site Mitigation MFR 2-26-2018 <br />