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SAN JOAN COUNTY ENVIRONMENTAL HEALTH DEATMENT AUG 25 2016 <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM tr,,;.'"RI'':41_ <br /> DATE 8/25/16 _.. <br /> SF/ADEb'liS FOR EHD VSE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: C ECKIFOWNERISCURRENTLYONF/LEW/TN EHD <br /> PROPERTY Jerry Robinson PHONE <br /> OWNER NAME FIRST M, LAST (209) 466-7915 <br /> BUSINESS NAME Dos Reis Ranch, Inc. E-MAILADDRESS <br /> OWNER HOME ADDRESS 7000 S Inland Dr ATTENTION:ORCARE OF/OPTR)NAIJ <br /> CITY Stockton, CA 95206 STATE zip <br /> OWNER MAILING ADDRESS same as above <br /> MAILING ADDRESS CITY STATE zip <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY 17 OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWOCB LEAD— RWOCB LED ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY DRI 2958 2954 <br /> 2950 2953 2960/352613527 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 IN NO ❑ <br /> BUSINESS/FACILITYISITEIPROJECTNAME City of Lathrop Consolidated Treatment Facility APN: 191-220-14 <br /> SUE ADDRESS I PROJECT LOCATION 14101 S. Manthey Road BUSINESS PHONE <br /> Ortr 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 11 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 /> MAILING ADDRESS P.O. Box 2401 PHONE <br /> (530) 759-2484 <br /> CITY Davis, CA 95617 STATE zip <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[] FACILITY/BUSINESS❑ THIRD PARTY BILLINGO <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant, certify that I at i the Owner,Operator,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHA ES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOIJNTADDRESS for his site.1 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 faii ility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as Soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT)SteVe DeVerel SIGNATURE <br /> TITLE President, HydroFocus, Inc. T"XID* 94-32$9577 <br /> FAM: OWNER IO*: ACCOUNT*: ASSIGNED TO: <br /> PR#: ACCOUNTING COMPLETED BY: <br /> DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />