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InaryA'^d, <br /> SAN JOIN COUNTY ENVIRONMENTAL HEALTH DORTMENT AUG 2 5 2016 <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 8/25/16 AF1AbEb1?1Ql51IS FOR EHD{TSE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: C EORIFOWNER is CuRRrNaYORFxE WITH EHD <br /> PROPERTYWidmer <br /> OWNER NAME AiICR FIRST ST PHONE 915-4245 <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OWNER HOME ADDRESS 12375 Droge Rd ATTENTION:ORCAREO t(OPTA)RAL) <br /> Gln Escalon, CA 95320 STATE ZIP <br /> OWNER MAILING ADDRESS same as above <br /> MAILING ADDRESS CIN <br /> STATE ZIP <br /> ❑CORPORATION ❑O INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑R SPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHDLOcALVOLUNTARY ❑ RWQCB LRWQCBL D— ❑ DTSC LEAD FEJFE�DEPALEADASSESSMENT CLEANUP CORRECTIVE AC TION WATER QUALITY DRI 2959 54 <br /> 2950 2953 29601352613527 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 /> BUSINESS/FACILITY/SITEIPROJECTNAMECity of Lathrop Consolidated Treatment Facility "P" 191-220-05 <br /> SITE ADDRESS/PROJECT LOCATION 12965 S. Manthey Road BUSINESS PHONE <br /> CITY Lathrop, CA 95330 STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT 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 /> BUSINESSNAME HydroFocus, Inc. ATTENTION:ORCARE OF(OPr"MAL) <br /> MAILING ADDRESS P.O. Box 2401 PHONE <br /> (530) 759-2484 <br /> CITY Davis, CA 95617 STATE ZIP <br /> -771 ACCGUNTAODRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <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 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 under fa ility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to AN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or m r¢ reSeD 8t1Ve. <br /> APPLICANT NAME(PLEASE PRINT)SteVe Deverel SIGNATUR <br /> TITLEPresident, HydroFocus, Inc. TAXID# 94-32E 1 19577 <br /> FA#: OWNER ID#I ACCOUNT#: ASSIGNED TO: <br /> PR#. ACCOUNTING COMPLETED BY: DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />