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SAN j­QUIN COUNTY ENVIRONMENTAL HEALTH L_,JARTMENT <br /> DATE January 30, 2013 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# FCA # OpUNIT IV <br /> SR (oL3 �� <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/FOWNERISCURRENrLYONFILEW/TH EHD <br /> PROPERTY OWNER NAME F <br /> Derone Thrasher (800)571-6143, cell 209-969-8163 <br /> FIRST Ml L4ST PHONE NUMBER <br /> BUSINESS NAME None-Private residence E-MAILAODRESS <br /> None <br /> OWNER HOME ADDRESS 2295 S. MacArthur Drive <br /> CITY Tracy STATE ZIP <br /> CA 95376 <br /> OWNER MAILING ADDRESS Same <br /> MAILING ADDRESS CITY STATE zip <br /> ❑CORPORATION L}INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# IF' <br /> NV# ACCOUNT ID P O# [flNED EMPLOYEE LEAD AGENCY:EHD X RWQCB_DTSC_EPA <br /> �l toSn 3`l"7 537(o0�f 4,V11 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: �S <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑6 <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESS/FACILITY/SITE/PROJECTNAME 2295 S. MacArthur Drive <br /> SITE ADDRESS I PROJECT LOCATION 2295 S. MacArthur Drive SUITE# BUSINESS PHONE <br /> CITE' Tracy I� FATE ZIP 95376 <br /> (BOAI,RD OFtSUPERVISOR DISTRICT LOCATION CODE 3 KE11 KEY2 <br /> LL�J' J��a CAr� Ul r Uf T FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITYSTATE ZIP 85376 <br /> Tracy l.H <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Tetra Tech ATTENTION:ORCARE OF (OPTIONAL) <br /> 4.1 G 0_; C/l <br /> MAILING ADDRESS 2969 Prospect Park Dr., Ste. 100 PHONE 916-853-1800 <br /> CITY Rancho Cordova STAT_ CA ZIP 95376 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINGIIN <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agen4 or Responsible Party and I actmowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed tome at the address identified above as the ACCOUNTADDRESS 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 applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agen4 or Responsible Party for the project local bq-Le under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN J0.4QUIN CDUT7'IV ENViRONhiEIVT.9LtIEA EP n as it is available <br /> and at the same time it is provided to me or my representative. // <br /> _fes'.. <br /> APPLICANT NAME <br /> �/11(PLEASE PRINT) �' 1�) SIGNATURE <br /> TITLE / � {/�<��// /������JJ-,,-�i ��...ttt,,, ?•L - TAX ID# <br /> f7APPROVED DATE ACCOUNnNG OFFICE PROCESSING COMPLETED BY DATE IAMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> 3 ' `J --- - �,- -r rfFe ----__— —=1 l �S�G 2 e.oLca,t�rR- ?_R`] - <br />