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x f ,y"4 '� R Pte' <br /> a �4 k �% '6=� ; <br /> SAN JOARQIN COUNTY ENVIRONMENTAL HEALTH DATMENT AUG 2 5 i" <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 8/25/16 SHADED AI?5,tS FOR EHD LVE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IPOwNERIs OURRENTLrONF/LE wiTH EHDO <br /> PROPERTY PHONE <br /> OWNER NAME FIRST ST (209) 941-7200 <br /> BUSINESS NAME City of Lathrop E-MAILADDRESS <br /> OWNER HOME ADDRESS 390 Towne Centre Drive ATTENTION:ORCARE OF(OPTIONAL) <br /> CITY Lathrop, CA 95330 STATE zip <br /> OWNER MAILING ADDRESS same as above <br /> MAILING ADDRESS CITY STATE LP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- M RWQCBLEAD- <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD E]FED EPA LEAD <br /> 2950 2953 2960/3526/3527 2965 2959 2954 <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 H <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES N No ❑ <br /> BUSINESS/FACILITYISITEIPROJECTNAME City of Lathrop Consolidated Treatment Facility I APN' Right-of-way <br /> SITE ADDRESS/PROJECT LOCATION E. Louise Ave, Rail Way, Village Ave, & Barbara Terry Ivd6USINESB PHONE <br /> CITY Lathrop, CA 95330 STATE zip <br /> BOARDOFSUPERVISOR DISTRICT LOCATION CODE KEY1 KEr2 <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 /> MAILING ADDRESS P.O. Box 2401 PHONE (530) 759-2484 <br /> CITY Davis, CA 95617 STATE zip <br /> ACCOIINTADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINGIN <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 facility/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 SIGNATUR <br /> TITLE President, HydroFocus, Inc. T"'DR 94-3289577 <br /> FA R: OWNER IDR: ACCOUNT R: ASSIGNED TO: <br /> PRR: ACCOUNTING COMPLETED BY: DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />