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STATE CA ZIP 95617 crrY Davis <br />THIRD PARTY BILLING] ACCOUNT ADDRESS To SEND FEES AND CHARGES: OINNERO FACILITY/BUSINESS <br />BUSINESS NAME HydroFocus, Inc. ATTENTION: ORCARE OF (0P770IVAL) <br />MAILING ADDRESS P.O. Box 2401 PHONE (530)759-2484 <br />APPLICANT NAME (PLEASE PRINT) Steve Deverel <br />TITLE President, HydroFocus, Inc. <br />SIGNATURE <br />TAxiD# <br />SAN JO' —1 1IN COUNTY ENVIRONMENTAL HEALTH r"-PARTMENT <br />SITE MITIG... ION MASTER FILE RECORD INFOK_ATION FORM <br />"MFR"- GREEN FORM <br />DATE 7/21/2017 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION.' CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />PHONE <br />(650) 632-4522 <br />FIRST MI LAST <br />BUSINESS NAME Saybrook CLSP, LLC E-MAIL ADDRESS <br />jwilson@saybrookfundadvisors.com <br />OWNER HOME ADDRESS 303 Twin Dolphin Dive, Suite 600 ATTENTION: ORCARE OF (OPTIONAL) Saybrook Fund Advisors, LLC <br />CITY Redwood Shores STATE CA ZIP 94065 <br />OWNER MAILING ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />El CORPORATION <br /> 1:1 INDIVIDUAL <br /> 0 PARTNERSHIP <br /> El GOVERNMENT AGENCY Cl RESPONSIBLE PARTY <br /> DR1 OTHER <br />In ENVIRONMENTAL II EHD LOCAL VOLUNTARY . RWQCB LEAD - kil RWQCB LEAD - <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />. 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 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES <br />E NO <br />K1 NO • <br />BUSINESS/FACILITY/SITE/PROJECT NAME Consolidated Treatment Facility, Central Lathrop Specific Plan area APN: 191-220 -13 <br />SITE ADDRESS / PROJECT LOCATION BUSINESS De Lima Road PHONE <br />cm' Lathrop STATE CA ZIP 95330 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY 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 />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 <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 />ENVIRONMEN I AL HEALTII DEPARTMENT as soon as it is available and at the same time it is • ed to • my represe tative. <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