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SAN JOuIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 10/14/2016 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS OVRRERnrONFNER/ EHID <br /> PROPERTY PNONE (209)952-6297 <br /> OWNER NAME IRST ST <br /> BUSINESS NAME Robinhood Plaza SC LLC EauILADDREee <br /> OWNER HOME ADDRESS ATTENTION:ORCARE OF(WTTOKAL) <br /> CITY STATE LP <br /> OWNER MAILING ADDRESS 1036 West Robinhood Drive Suite 202 <br /> MARINO ADDRESS CITY Stockton STATE CA LP 95207 <br /> Z CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ <br /> ENVIRON MENTAL ❑ EHD LOCAL VOLUNTARY RWQCBLEAD— ❑ RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP C CTIVE ACTON WATERQUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES I® No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No ❑ <br /> BU8INEBBIFACILm/SmEIPNoJECTNAME C&S Cleaners �] APN: <br /> Sme ADOREss/PRQIECTLOCAnON 5756-RIobin4l� BUSINESS PHONE <br /> Cm Stockton STATE CAzIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CM STATE ZIP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Terraphase Engineering,Inc. ATTENTION:ORCARE OF(OPT)MIL/ Scott Seyfried <br /> MAILING ADDRESS 2330 E.Bidwell Street,#211 PHONE (916)594-8499 <br /> C" Folsom STATE CA LP 95630 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACIUTYIBUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PE"IT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site.I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQWV COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPucANT NAME(PLEASE PRINT) James Scott Seyfried SIGNATURE <br /> TITLE Principal Hydrogeologiat,Project Manager TM IID## r <br /> FA III: D I OWNER 10 111: ACCOUNT#' 117 ASSIGNED TO: <br /> OD 3 <br /> PR#: pgo 5�7 591 ACCOUNTING COMPLETED BY: DATE: 10 I1 Op <br /> II <br /> 9-3-2015 V <br /> Site Mitigation MFR 29- <br />