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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTRECEIVED <br />SITE MITIGATION MASTER FILE RECORD INFORMATION it F°RVIjUl- 1 9 201/ "MFR"- GREEN FORM <br />DATE <br />07/14/2017 <br />EltAROWENTALFR USE <br />FLRIWITSERvir_r_e <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK /F OWNER IS CURRENTLY ON-FICE•WWW CND <br />PROPERTY <br />OWNER NAME <br />FUSan 1 3e1 1 ' (_,:3 f::: PHONE <br />FIRST MI Lz ' <br />BUSINESS NAME River Islands Development LLC E-MAIL ADDRESS <br />OWNER NOME ADDRESS 73 Stewart Road ATTENTION: OR CARE OF (0P770NAL) <br />CITY Lathrop <br /> STATE CA <br /> <br />ZIP 95330 <br />OWNER MAILING ADDRESS SAME AS ABOVE <br /> <br />MAILING ADDRESS CfTY <br /> STATE ZIP <br /> <br />0 CORPORATION <br /> El INDIVIDUAL <br /> El PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY D RESPONSIBLE PARTY <br /> <br />0 OTHER <br />E EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />RWQCB LEAD — El ENVIRONMENTAL RWQCB LEAD — U DTSC LEAD FED EPA LEAD <br />ASSESSMENT <br />2950 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 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? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES El No 0 <br />YES 0 No 0 <br />BusiNess/FAcuLny/SITE/PpoJEcT Num River Islands - Stage 2B MWR-8 APN, 213-23-006 <br />SITE ADDRESS / PROJECT LOCATION 16976 Cohen Road BUSINESS PHONE <br />Cm Lathrop STATE (7; ZIP 95330 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE I <br />1 Key1 I ' KEr2 1 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CfTY STATE ZIP <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 ENGEL), inc ATTENTION: ORCARE OF (OPTIONAL) <br />MAILING ADDRESS 172713 Golden valley Parkway PHONE 2096847634 <br /> <br />CITY Lathrop STATE CA ZIP 95330 <br />1 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> OWNERD <br /> <br />FACILITYIBUSINESSEI <br /> <br />THIRD PARTY BILLINGO <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 m presenta • . <br />APPLICANT NAME (PLEASE PRINT) Ma Lus SIGNATURE <br /> <br />TITLE Slaff Engneer <br /> <br />TAX ID* <br /> <br />_ <br />FA #: _ <br />iik -VO -t-I'l6-dG' <br />OWNER ID O: <br />01,4)D0 -2L•le 1-7 <br />ACCOUNT 0: <br />PC12.490 1.1-44-8q 5 ASSIGNED TO: <br />PR #: <br />,P12.o5 41.2-0 (pi, <br />ACCOUNTING COMPLETED BY: <br />(I-) <br />DATE: ii 2..0 i <br />/ / / <br />9-3-2015 <br />Site Mitigation MFR 29-