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® ` 'D SAN JOIN COUNTY ENVIRONMENTAL HEALTH DORTMENT <br /> AU� 2 5 2016 SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 18/25/16,1,,FAL SHADED AREAS FOR EHD USE <br /> ff}�}tt� „I <br /> bWNER FlCE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNECKIPOWNER ISCURRENTLY ON FILE WITH EHD <br /> PROPERTYSusan Dell'Osso PHONE <br /> OWNER NAME FIRST ST (209) 879-7900 <br /> BUSINESS NAME Califia LLC EMAIL ADDRESS <br /> OWNER HOME ADDRESS 73 Stewart Road ATTENTION:ORCAREO (OPTR AL) <br /> °in Lathrop, CA 95330 STATE zip <br /> OWNER MAILING ADDRESS same as above <br /> MAILING ADDRESS CITY STATE zip <br /> ❑E CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑R SPONSIBLE PARTY <br /> ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- X RWQCB L D- <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY LFP <br /> ❑ DTSC LEAD F10JFED EPA LEAD2950 2953 2960/3526/3527 2965 2959 954 <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 A NEW SCOPE OF WORK? YES I] No ❑ <br /> BUSINESSMACILITYISITEIPROJECT NAME City of Lathrop Consolidated Treatment Facility APN' 213-300-07 & 213-230-05 <br /> SITE ADDRESS/PROJECT LOCATION River Islands - 73 W. Stewart Road BUSINESS PHONE <br /> CITY Lathrop, CA 95330 STATE zip <br /> BOARDOFSUPERVISOR DISTRICT I LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 390 Towne Centre Drive <br /> MAILING ADDRESS CITY Lathrop, CA 95330 STATE ZIP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME HydroFocus, Inc. ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILINGADDRESS P.O. Box 2401 PHONE <br /> (530) 759-2484 <br /> CITY Davis, CA 95617 STATE ZIP <br /> ACCOUNTADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING❑O <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, 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 ACCOUNTADDRESS for this site.I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator, Authorized Agent, or Responsible Party for the project located above und4toAN <br /> ity/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as Soon as it is available and at the Same time it is provided to me or mesentative. <br /> APPLICANT NAME(PLEASE PRINT)Steve Deverel SIGNATURE <br /> TITLE President, HydroFocus, Inc. T-'D# 94-3289577 <br /> FA#: OWNER ID#: ACCOUNT#: AS8IGNED TO: <br /> ACCOUNTING COMPLETED BY: DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />