SITE INFORMATION AND CORRESPONDENCE_CASE 2

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San Jo ain County Environmental Health C artment DATEIW �/ MASTER FILE RECORD INFORMATION"MFIR GREEN FORM SITE MITIGATION& LOP SHADED AREAS FOR END USE ONLY LOWNER ID# CASE#�jZ(JD l'( _,7�/ UNIT IV OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMA TION.- CHECK,/Fc OWNER CURRENTLYONF/LEW/TH EHD PROPERTY OWNER NAME 916)941 2920 First MI Last PHONE NUMBER BUSINESS NAME CEMEX E-MAIL ADDRESS emanzo@somaenv.com Owner Home Address 5180 Golden Foothill Parkway, Suite 200 City El Dorado Hills STATE ZIP 95762 CA 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 SfTIL'MITIGATION__ENVIRONMENTAL AssEsaMENT-VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION LOP X 1737 FACILITY ID# INV# AccouNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB DTSC_EPA_ 383 0:.- FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON: 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 BUSINEss/FACILITY/SITENAME RMC PACIFIC MATERIALS - T0607700371 SITEADDRESS 30350 TRACY BLVD S SUITE# BUSINESS PHONE CITY TRACY STATE p, ZIP 5375 L!=FSUPERVISORDISTRICT O LOCATION CODE KEY1 KE y2 Address ND/FFERENT from Facility Address Attention:or Care Of(optional) E Address City STATE ZIP E 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 Cm Pleasanton STATE CA ZIP 94588 AccouNTADORESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING HILLING AND COMPLIANCE AC'K.NOW LED(,NI FN I: I,the undersigned Applicant,certify that I am the[Miter,[Operator,or Authorized:igent of this Business,and 1 acknowledge that all PERwr FEES, PFN;I[ITEt•,ENFORCEMENTCHARGES and/or lit'/R1 014RGES associated with this operation will he billed to me at the address identified above as the Accot/A1ADORESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will he 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,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 assoonas it is available and at the same time it is pr—ided to me or my representative. APPLICANT NAME(PLEASE PRINT) LOU 1 S S c h i pp e r SIGNATURE TITLE Sr . Eiivironmerita1 Manager TAx1D# �APProved By Date Accounting Office Processing Completed By Date Y1'rW 7 Z SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# REC IVED BYPLAN PE Fee$ _- --