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San Joaquin County Environmental Health Department <br /> cc » GREEN FORM <br /> DATE 9/8/2014 MASTER FILE RECORD INFORMATION MFR SITE MITIGATION 8L LOP <br /> UNIT IV <br /> SHADED AREAS FOR EHO USE ONLY OWNER ID# <br /> CASE# <br /> OWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OWNER CURRENTLYON F/LE WITH EHD <br /> PROPERTY OWNER NAME <br /> Port of Stockton (209) 946-0246 <br /> First <br /> Mt Last PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME port of Stockton <br /> Owner Home Address 2201 W.Washington St. <br /> STATE; <br /> OA ZIP 95203 <br /> city Stockton <br /> Owner Mailing Address See Above <br /> State Zip <br /> Mailing Address City <br /> AGENCY ❑RESPONSIBLE PARTY OTHER <br /> El CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ®GOVERNMENT <br /> ❑ <br /> OLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT V <br /> DTSC EPA <br /> FACILITY ID# INV# ACCOUNT ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_ _ <br /> Jv It <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El NOE] <br /> YES ❑ NO C$ <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? <br /> BUE <br /> ACILITYISITEIPROJECTNAME MO-1,Rough and Ready Dredge Materials Placment Site <br /> SUITE# BUSINESS PHONE <br /> $ITSS I PROJECT LOCATION 206 Hooper St. <br /> STATE ZIP 95203 <br /> CITY Stockton CA <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE <br /> KEvi KEv2 <br /> Attention:orCare Of(Optional) <br /> Mailing Address IF DIFFERENTfrom Facility Address 2201 W.Washington St. <br /> STATE zip <br /> Mailing Address City Stockton <br /> SIC CODE APN# 16203007 COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or ResponsibleParty identified above. <br /> Attention:orCare Of (optional) <br /> BUSINESS NAME Environmental Risk Services <br /> Mailing Address 1600 Riviera Ave. Ste. 310 PHONE (925) 938-1600 <br /> STATECA <br /> zIP 94596 <br /> CITY Walnut Creek <br /> ASOo_uNrADDREsc for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COhIPLLANCE ACKtvOwi.eDGnlEta'ra [,the undersigned Applicant,certify that I am the Orvner,Operator,Authortced Agent'or Responsible Party and I acknowledge that all PER:t717 FEES, <br /> PE,vALrrEs,ExFOItCEatE:v�CHARGES and/or Hoc�RLY CHARGES associated with this project will be billed to me at the address identified above as the Accotm AnflREssfor 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 applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL.Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> is available and at the same time it is provided to me or my representative. <br /> SIGNATOR <br /> APPLICANT NAME(PLEASE PRINT)Maxwell Balbin <br /> TAXID# <br /> TITLEProject Scientist <br /> Approved By Date Accounting Office Processing Completed BT_- Date <br /> RECEIPT# K# RECEIVED BY WORK PLAN PE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE 7 <br /> FEE:$ `J[O 3 T O /� <br />