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SAN JO IN COUNTY ENVIRONMENTAL HEALTH DI PARTMENT DATE March 19, 2014 MQER FILE RECORD INFORMATION 4� IIIi�K�� GREEN FORM SITE MITIGATION & LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNERS CURRENTL YON FILE wTH EHD PROPERTY OWNER NAME Port of Stockton (209) 946-0246 FIRST MI LAST PHONE NUMBER BUSINESS NAME Port of Stockton E-MAIL ADDRESS OWNER HOME ADDRESS 2201 W. Washington St. CITY Stockton STATE ZIP CA 95203 OWNER MAILING ADDRESS 2201 W. Washington St. MAILING ADDRESS CITY Stockton STATE CA ZIP 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 T LEAD AGENCY:EHDRWQCB_DTSC_EPA_ 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/FACILITYISITE/PROJECTNAME UP Welding Facility, Landfill Areas, RRI SITE ADDRESS/PROJECT LOCATION Shipley Road at Humphreys Dr. SUITE# BUSINESS PHONE CITY Stockton STATE ZIP CA 95203 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 2201 W. Washington St. ATTENTION:OR CARE OF(OPTIONAL) MAILING ADDRESS CITY Stockton STATE CA vP 95203 SIC CODE [t�� COMMENT: 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 1600 Riviera Ave Suite 310 PHONE 925-938-1600 CITY Walnut Creek STATE CA ZP 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,Authorized Agent,or Responsible Party and I acknowledge that all PERMIT FEES, PENALI7ES,ENFORCEMENT CHARGES and/or HouRLYCHARGES associated with this project will be billed tome at the address identified above as the ACCOUNTADORFSS for this site. I also certify that all 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 STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Parry 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. APPUCANTNAME(PLEASE PRINT) Leslie Shields, ERS Corp SIGNATURE TITLE Project Scientist TAx ID# 36-4459849 APPROVED BY I DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEE:$ I J