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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 12/01/2016 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER 19 CURRENTLY ON FILE WTI/ EHD <br />PROPERTY <br />OWNER NAME <br />Knife River Corporation PHONE <br />209 - 948 -0302 FIRST MI LAST <br />BUSINESS NAME <br />Knife River Corporation <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: OR CARE OF (0P710AL4L) <br />655 West Clay Street Steve Azevedo <br />CrrY Stockton STATE CA z'P 95206 <br />OWNER MAIUNG ADDRESS PO Box 6099 <br />MAILING ADDRESS CITY Stockton STATE CA zw 95206 <br />CORPORATION <br /> <br />0 INDIVIDUAL <br /> <br />0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />M ENVIRONMENTAL N EHD LOCAL VOLUNTARY RWCICB LEAD — <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WDR) <br />2965 <br />M 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 El No g <br />iS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YEs XX No 0 <br />BUSINESSIFACIUTY/SITE/PROJECT NAME Knife River Construction / West Clay Property APN: <br />SITE ADDRESS / PROJECT LOCATION <br />655 West Clay Street <br />BUSINESS PHONE <br />cITY Stockton STATE CA LP 95206 <br />BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I K KEY2 I <br />MAIUNG ADDRESS , IF DIFFF_RENT FROM FACIUTY ADDRESS piv Th D0X an uv99 Box <br />MAIUNG ADDRESS CITY Stockton STATE CALP 95206 <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME <br /> <br />ATTENTION: ORCARE OF (OPTKWAL) <br />MAIUNG ADDRESS <br /> <br />PHONE <br />STATE <br /> <br />ZIP <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNER[ <br /> <br />FACILITY/BuSINESSO <br /> <br />THIRD PARTY BILLINGO <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 information <br />provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br />JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br />Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br />release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my repr,e4entative. , <br />William Little <br />APPLICANT NAME (PLEASE PRINT) <br /> <br />SIGNATURE <br /> <br />TITLE Agent - Geologist <br /> <br />TAX ID* <br /> <br />FAN: 6466 <br />2 S 77 7 <br />OWNER ID III ACCOUNT ik Aieayi.,±a,..3 ASSIGNED TO: <br />PRII: , pe 1 4.07 ACCOUNTING COMPLETED BY: <br />g) <br />DATE: i 2_154 <br />9-3-2015 <br />Site Mitigation MFR 29-