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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM �. "MFR"-GREEN FORM DATE 5/26/2020 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIF OWNER IS CURRENTLYONFKE wnN EHD ❑X PROPERTY PHONE OWNER NAME I-IRST M1 I LAST BUSINESS NAME E-MAIL ADDRESS Lincoln Center Environmental Remediation Trust OWNER HOMEADDRESS ATTENTION:ORCARE OF(CPTIOrui) Joseph Niland CITY (' t i' r, C.� /uLMI`�y ( _ � STATE ZIP �[ OWNER MAILING ADDRESS 7 �,(��r7 (LG�Y /VAI, _ OI— tadia:anb MAILING ADDRESS CRY '3 69I'daya �1^'y t✓—�''�-rc fL�� ,,,ATE CA ZIP -55eTu- ❑CORPORATION ElINDIVIDUAL ❑PARTNERSHIP ElGOVERNMENT AGENCY ElRESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY FKJ RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 2950 2953 2960/3526/3527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No [3t IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES [X No ❑ BUSINESSIFACILRYISITEIPROJECTNAME Lincoln Center Environmental Remediation Trust APN 09741079 SITE ADDRESS I PROJECT LOCATION W Benjamin Holt Dr BUSINESS PHONE 916-637-8325 rc—r- Stockton STATE CAZIP 95207 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY'I KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 3043 Gold Canal Drive, Suite 100 c/o Joseph Niland MAILINGADDRESSCITY Rancho Cordova STATE CAZ'P 95670 SIC CODE COMMENT REQUESTOR'S INFORMATION: BUSINESS NAME Geosyntec Consultants, Inc. ATTENTION Pete Dennehy MAILINGADDREW 3043 Gold Canal Drive PHONE 916-637-8341 CITY Rancho Cordova STATE CA ZIP 95670 E—IL PDennehy@Geosyntec.com ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR[X BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated 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 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 located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pr vided to me or my representative. APPUCANTNAME(PLEASEPRINT) Arthur Forma SIGNATURE TITLE Senior Principal Hydrogeologist TA"ID# 59-2355134 FA 0: OWNER ID#: �� ACCOUNT>lk: pAO ASSIGNEDTO: PRO: A ACCOUNTING COMPLETED BY: - a DATE: SR TYPE PE SCS FE AMT REMI ED CHECK# RECV D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2903 523 $456.00 /t_� rG�16 G 2904 523 `T . 10l �f Site Mitigat'on MFR 2-26-2018 y �lLt