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SAN.J WIN COUNTY ENVIRONMENTAL HEALTH ARTMENT DATE January 30, 2013 MASTER FILE RECORD INFORMATION "MFR" 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 Y ON FILE WITH EHD PROPERTY OWNER NAME Derone Thrasher (800)571-6143, cell 209-969-8163 I FrRsr MI L4ST PHONE NUMBER BUSINESS NAME None-Private residence E-MAIL ADDRESS None OWNER HOME ADDRESS 2295 S. MacArthur Drive CITY Tracy STATE ZIP CA 95376 OWNER MAILING ADDRESS Same MAILING ADDRESS CITY STATE ZIP ❑CORPORATION I�INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# ACCOUNT ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA JoJlutiy FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW 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 Bus INESS/FACILITYISITEIPROJECTNAME 2295 S. MacArthur Drive SITE ADDRESS I PROJECT LOCATION 2295 S. MacArthur Drive SUITE# BUSINESS PHONE CITY Tracy ( J $Ti1TIE ZIP 95376 BOARD OF SUPERVISOR DISTRICT \ LOCATION CODE J KEY1 KEY2 LL�J�OMa C'XRhDUr UrE T ROM FAC.IJLITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) MAILING ADDRESS CITY 3ZgTE ZIP 95376 Tracy ll AN $IC CODE APN# COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Tetra Tech ATTENTION:ORCARE OF (OPTIONAL) C(Os c Wo MAILING ADDRESS 2969 Prospect Park Dr., Ste. 100 PHONE 916-853-1800 CITY Rancho Cordova STA-- CA ZIP 95376 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the(honer,Operator,.Authorized Agent,or Responsible Party and I acknowledge that all PER,NLT FEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated With this project will be billed to me at the address identified above as the ACCDUNTADDRESS 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 Party for the project local a under facility/site address,I hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQU(N COUNTY ENVIRONMENT. EP�DY,es it is available and at the same time it is provided to me or my representative., / APPLICANT NAME(PLEASE PRINT) xi /�'> ) y� SIGNATURE M ) - / TITLE {��v/�/% ;r ((( ,� �7'� ✓ TAx ID# APPROVED BY ` DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNTtPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEE: �'� ?S� _ �o Cu�N 1—G-2