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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTA, <br />SITE MITIGATION MASTER FILE RECORD INFORMATION F Rec <br />"MFR"- GREEN FORM <br />DATE 04/23/2019 k., MikreEAS FOR EH USE <br />I <br />OWNER FILE: COMPLETE PROPERTY OWNEFfiPONSIBLE PAINFORMATION: <br />407 <br />CHECK IF OWNER IS cel pziLE wPEHD <br />PROPERTY <br />OWNER NAME <br />41-.4" PHONE 4E407y <br />FIRST MI LAST <br />BUSINESS NAME Kearney - National Inc. E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTRITION: ORCARE OF (OP770N4L) <br />Crry STATE ZIP <br />OWNER MAILING ADDRESS 2515 South Road, 5th Floor <br />MAIUNG ADDRESS CITY Poughkeepsie STATE NY ziP 12601 <br />0 CORPORATION <br /> <br />0 INDIVIDUAL <br /> CI PARTNERSHIP CI GOVERNMENT AGENCY a RESPONSIBLE PARTY <br /> I2 OTHER <br />ENVIRONMENTAL . EHD LOCAL VOLUNTARY RWQCB LEAD— 111 RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />ri DTSC LEAD FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES CI No a <br />Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES IA No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Former Kearney - KPF Facility APN 11708006 <br />SITE ADDRESS / PROJECT LOCATION BUSINESS PHONE 1624 E Alpine Ave <br />Cify Stockton STATE CA ZIP 95204 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil Kea <br />MAIUNG ADDRESS, IF DIFFERENT FROM FACIUTY ADDRESS 2515 South Road, 5th Floor <br />MAIUNG ADDRESS CITY Poughkeepsie sum Ny zip 12601 <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br /> <br />BUSINESS NAME Dudek <br /> <br />A'N Glenna McMahon <br /> <br />MAIUNG ADDRESS 605 2nd Street <br /> <br />PHONE 760-479-4130 <br /> <br />CITY Encinitas STATE CA ZIP 92075 EMAIL gmcmahon@dudek.com <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OwNERD <br /> <br />FACILITY/BUSINESS El <br />REQUESTOR a <br /> <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 PERMIT 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 ACCOUNT ADDRESS 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 <br />applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br />undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />C\ <br />A: <br /> <br />TrrLE Principal Engineer <br /> <br />TAxlqf <br /> <br />FA #: FA Ot,is-22/ Al OWNER ID ft: <br />23 <br />f I 6, ACCOUNT #: 4 ,71-7,71(N, ASSIGNED TO: ASSIGNED <br />PR #: ?goss-4.1 L/62..._ ACCOUNTING COMPLETED BY: DATE: 36 <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REMIT BY DATE SERVICE REQUEST. INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 Si-igle los-cm1 1„,V cl, I ri 5 Pao Kos-s--9 <br />ofre. <br />APPLICANT NAME (PLEASE PRINT) Glenna McMahon SIGNATUR <br />Site Mitigation MFR 2-26-2018