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IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br /> <br />YES LI <br />No al <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br /> <br />YES El <br />No I=1 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Consolidated Treatment Facility, Central Lathrop Specific Plan area APN: 191-210-08 <br />SITE ADDRESS / PROJECT LOCATION Golden Valley Parkway BUSINESS PHONE <br />CITY Lathrop <br />STATE CA ZIP 95330 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil Ker2 <br />MAIUNG ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />CITY Davis STATE CA ZIP 95617 <br />THIRD PARTY BILLING] ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OVVNEREI FACILITY/BUSINESSO <br />BUSINESS NAME HydroFocus, Inc. ATTENTION: ORCARE OF (OPT/ONAL) <br />MAILING ADDRESS P.O. Box 2401 PHONE (530)759-2484 <br />SITE MITIG. _ ION MASTER FILE RECORD INFOI. ATION FOgECEIVED <br />SAN JO' JIN COUNTY ENVIRONMENTAL HEALTH r"PARTMENT <br />"MFR"- GREEN FORM <br />DATE 7/21/2017 <br />/LI I I <br />SHA IDiEY)tjARAiS FOA' END USE <br />k i 11•,•,.., , -:., it; <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS 00 " 4. "441,0,1,11 <br />_ <br />:flt <br />PROPERTY <br />OWNER NAME <br />PHONE (650) 632-4522 <br />FIRST MI LAST <br />BUSINESS NAME Saybrook CLSP, LLC ADDRESS E-MAIL . <br />OWNER HOME ADDRESS 303 Twin Dolphin Drive, Suite 600 ATTENTION: ORCARE OF (OPTIONAL) Saybrook Fund Advisors, LLC <br />crrr Redwood Shores STATE CA Zip 94065 <br />OWNER MAILING ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />CORPORATION <br /> <br />INDIVIDUAL <br /> <br />PARTNERSHIP <br /> <br />El GOVERNMENT AGENCY LI RESPONSIBLE PARTY <br /> <br />OTHER <br />E ENVIRONMENTAL M EHD LOCAL VOLUNTARY RWQCB LEAD — r.1 RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (VVDR) <br />2965 <br />. DTSC LEAD U FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />THIRD PARTY BILLING INFO COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Parry 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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br />undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is proviel to me or m epresentative. <br />APPLICANT NAME (PLEASE PRINT) Steve Deverel SIGNATURE <br />TITLE President, HydroFocus, Inc. TAX ID # <br />FA #: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$390.00 <br />$650.00 <br />9-3-2015Site Mitigation MFR 29- XXX 6-2-2017