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SAN JC AN COUNTY ENVIRONMENTAL HEALTH ' 'ARTMENT DATEMarch 19, 2014 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM -L �J SITE MITIGATION & LOP SHADED AREAS FOR EHD USE ONLY OWNER ID#b� �O� C( v CASE# uoc)(JQ 382, UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. 1 CHECK IF OWNER IS CURRENTL YON FILE WITH EHD PROPERTY OWNER NAME Port of Stockton (209)946-0246 FIRST Ml LAST PHONE NUMBER BUSINESS NAME Port of Stockton E-MAIL ADDRESS OWNER HOME ADDRESS 2201 W. Washington St. CITY Stockton STATE CA ZIP 95203 OWNER MAILING ADDRESS 2201 W.Washington St. MAILING ADDRESS CITY Stockton STATE CA LP 95203 ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY X HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB DTSC_EPA_ MOD t�7 (0 1PP__0P5-5819 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES [ No ❑ BUSINESS/FACILITv/SITE/PROJECTNAME UP Welding Facility, Landfill Areas, RRI SITE ADDRESS/PROJECT LOCATION Shipley Road at Humphreys Dr. SUITE# BUSINESS PHONE CITY Stockton STATE CA zip 95203 BOARD OF SUPERVISOR DISTRICT V� LOCATION CODE V ( KEY1 KEYZ MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 2201 W. Washington St. ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY Stockton STATE CA ZIP 95203 [!ff ff�/ COMMENT: 2 .o _v THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ERS Corp ATTENTION:ORCARE OF (OPTIONAL) MAILING ADDRESS PHONE 925-938-1600 1600 Riviera Ave Suite 310 CITY Walnut Creek STATE CA ZIP 94596 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Anthorized Agent,or Responsible Parry and I acknowledge that all PERMIT FEES, PENALTIES,ENFORCEAtENT CHARGES and/or HOURLY CHARGES associated with this project will be billed to me at the add ress identified above as the ACCOUNTADDRESs for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities i6ll be performed in accordance With all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or 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 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 is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Leslie Shields, ERS Corp SIGNATURE TITLE Project Scientist TAXID# 36-4459849 APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY W^7--PLjOWE FEE:$ Qottw I�7�{OQ