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San Jo3yuin County Environmental Health D'95artment DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM /� SITE MITIGATION& LOP SHADED AREAS FOR EHO USE ONLY OWNER ID# CASE# S v� ��,Z UNIT IV OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATlow 1 CHECKIF OWNER CURRENTLYONFILEW/TH EHO PROPERTY OWNER NAME CEMEX 916)941 2920 First MI Last PHONE NUMBER BUSINESS NAME CEMEX E-MAILADORESS emanzo@somaenv.com Owner Home Address 5180 Golden Foothill Parkway, Suite 200 City E1 Dorado Hills STATECA ZIP 95762 Owner Mailing Address 5180 Golden Foothill Parkway, Suite 200 Mailing Address City El Dorado Hills State CA Zip 95762 CORPORATION El INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ SffE MITIGATION ENVIRONMENTAL ASSESSMENT x VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INV/ESTIGATION_LOP x 1737 FACILITY ID# INV# ACCOUNT ID PR#/ O# ASSIG E MPLOYEE LEAD AGENCY:EHD I' RWQCB_DTSC_EPA FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION- Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Q Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No Q BUSINEWFACILITYISITE NAME RMC PACIFIC MATERIALS - T0607700371 SITEADDRESS 30350 TRACY BLVD S SUITE# BUSINESS PHONE NA CITY TRACY STATE CA ZIP95376 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY! KEY2 1� Mailing Address ifD/FFERENTfrom FaciiitvAddress Attention:or Care Of(optionall Mailing Address City STATE ZIP SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME SOMA Environmental Engineering, Inc Attention:orCare Of(optional) Mr. Mansour Sepehr Mailing Address 6620 Owens Drive, Suite A PHONE 925-734-6400 CITY Pleasanton STATE CA ZIP 9458 AccoutvrARDAEM for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Onvier,Operator,or,luthorizedAgent of this Bnki ess,and I acknowleedd2e-that all PEnMITFEF,.S, PE.N,ILTIFS,ENFORCEMEA7 CHARGES and/or HOURLYCH.4RGES associated with this operation Will be billed tome at the address identified above as the ACCOU �/iF3SYbr fh's 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 JO.AQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon ^^ n�»as it is available and at the same time it is pr tome representative. 'el.44%x APPLIPPLI NCANT NAMME(PLEASE PRINT) Louis S ch ippe r SIGNATURE TITLE Sr. Environmental Manager TAX ID# > Approved By Oate Accoun Ung Office Processing Completed By Date Z SITE MITIGATION AMOU N7 PAID DATEOF PAYM ENT PAYMENT TYPF_ RECEIPT# CHECK# RE'DD V/E�D WORK PIAN PE FEE:$ .. --.• - _:—