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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 5/31/2018 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNERISCURRENnYON FILE wirH EHD <br /> PROPERTY Phil Prassas PHONE <br /> 949-698-8482 <br /> OWNER NAME --FIRST ST <br /> BUSINESS NAME CHI LTH GP, LLC E-MAILADDRESS <br /> OWNER HOME ADDRESS 527 W. 7th Street, Suite 308 ATTENTION:ORCARE OF(OPT)UMU) <br /> CITY Los Angeles STATE CA ZIP 90014 <br /> OWNER MAILING ADDRESS SAME AS ABOVE <br /> MAILING ADDRESS CITY STATE ZIP <br /> ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> x❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑FED EPA LEAD <br /> 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? YESx❑ No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No x❑ <br /> BUSINESS/FACILITY/SITEIPROJECTNAME South Lathrop Commerce Center APN 241-02-070 <br /> SITE ADDRESS I PROJECT LOCATION 200 E Madruga St BUSINESS PHONE <br /> CITY Lathrop STATE CA ZIP 95330 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE COMMENT: <br /> REQUESTOR°S INFORMATION: <br /> BUSINEBs NAME ENGEO, Inc ATTENTION Ana Lua <br /> MAIUNGADDRESS 17278 Golden Valley Parkway PHONE 209-684-7604 <br /> CITY Lathrop STATE -A ZIP 95330 EMAIL alua@engeo.com <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTORI] <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 /> ENYHtONMENTAL 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) Ana We SIGNATURE 6�- <br /> TITLE Staff Engineer TAXID# 94-174-8418 <br /> FA 9: OWNER ID 0: ACCOUNT#: A331GNED TO: <br /> PR#: ACCOUNTING COMPLETED BY: DATE: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 2903 523 $456.00 <br /> 2904 523 $760.00 <br /> Site Mitigation MFR 2-26-2018 <br />