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DATE <br />CASES OWNER IOU <br />CHECK IF OWNER CURRENTLY ON FILE WITH EHD 111 OWNER FILE: COMPLETE PROPERTY OWNER! RESPONSIBLE PARTY INFORMA770N: <br />LOP SITE MITIGATION X ENVIRONMENTAL ASSESSMENT _ VOLUNTARY CLEANUP _ WATER QUALITY HW PIPELINE INVESTIGATION <br />SITE ADDRESS I PROJECT LOCATION 801 Diamond St. <br />Stockton STATE a zip - 95205-7019 <br />Attention: orCare Of (optional) Mailing Address If DIFFERENT from Facility Address <br />STATE ZIP Mailing Address City <br />APNO COMMENT: <br />Attention: orCara Of (optional) Mike McLeod Kennedy/Jenks Consultants. Inc. BUSINESS NAME <br />PH"E • 415-243-2150 Wining Address 303 Second St. Ste. 300 South <br />CITY San Francisco STATE Ca ZIP 94107 <br />OWNER FACILITY/BUSINESS THIRD PARTY SLUNG <br />San Joaquin County Environmental Health Department <br />MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br />SITE MITIGATION & LOP <br />UNIT IV <br />PROPERTY OWNER NAME Contact: Mike Makerov BNSF Railway ) 909-3864081 <br />PI, st MI Last PHONE NUMBER <br />BUSINESS NAME BNSF Railway E-MAIL ADDRESS <br />Owner Home Address <br />City STATE ZIP <br />Owner Mailing Address 740 East Carnegie Drive <br />Mailing Address City San Bernadino State Ca Zip 92408-3571 <br />X CORPORATION El INDIVIDUAL El PARTNERSHIP 0 GOVERNMENT AGENCY X REsPONSISLE PARTY I: OTHER <br />BusiNEss/PAnitrrY(SITE/PaosiEcT NAME BNSF Railway Mormon Rail Yard <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br />THIRD PARTY BILLING INFO Complete if Billing Party is different from Property Owner orResponsible Party identified above. <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, his undersigned Applicant, certify that I am the Owner, Operator, Autitorked Agent, or Responsible Party and I acknowledge that all PERMIT FEES, <br />PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the i4ccociirr Amin:S.1 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 applicable SAN JOAQUIN COUNTY Ordinance Cedes and/or <br />Standards and STATE aud/or FEDERAL Laws and Regulations. As the undersigned Owner, Operator, Authorized Agent, or Responsible Pai for the project located above under facility/site address, I <br />hereby authorize the release of any and all results, reports, tial other environmental assessment information to SAN JOAQUIN COUNTY/ MONMENTAL HEALTH DEPARTMENT as soon as it <br />Is available and at the same time it is provided to :no or my representative. <br />APPLICANT NAME (PLEASE PRINT) Mike McLeod <br />TITLE Geologist <br />Approved By Data Acoounting Office Processing Completed By Date <br />SITE MITIGATION <br />FEE; $ <br />AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT # <br />_.. . I <br />CHECK # <br />--- <br />RECEIVED BY <br />• i•— <br />1 <br /> AcatuatrAPDREss for fees and charges <br />SUITE A BUSINESS PHONE <br />209-460-6336 <br />SHADED AREAS FOR EHD Use ONLY <br />Tax ID # <br />SIGNATURE <br />SIC CODE