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SAN Jo A 'N COUNTY ENVIRONMENTAL HEALTH C '‘RTMENT <br />SITE MITIGh. ION MASTER FILE RECORD INFORiv.,,TION FORM <br />"MFR"- GREEN FORM <br />DATE 7/18/18 SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CLIRREWLY ON FILE WITH EHD MI <br />PROPERTY <br />OWNER NAME <br />PHONE <br />FIRST MI LAST <br />BUSINESS NAME Manteca Unified School District <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS 2271 W Louise Ave ATTENTION: ORCARE OF (OPTIONAL) <br />Crry STATE ZIP Manteca CA 95337 <br />OWNER MAILING ADDRESS Same as home address <br />MAILING ADDRESS CITY STATE LP <br />CORPORATION <br /> <br />INDIVIDUAL <br /> <br />I=1 PARTNERSHIP <br /> LNI GOVERNMENT AGENCY 111 RESPONSIBLE PARTY <br /> D OTHER <br />ENVIRONMENTAL m EHD LOCAL VOLUNTARY RWQCB LEAD — RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (VVDR) <br />2965 <br />II 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? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES 0 No N <br />YES [E No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Previous Site Address/Name: 453 Moffat Blvd APN <br />221-080-040 <br />SITE ADDRESS! PROJECT LOCATION <br />371 S Garfield Ave <br />BUSINESS PHONE , - I <br />CITY Manteca STATE LP CA 95336 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE , Kerl KEr2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />REQUESTOR9 S INFORMATION: <br />BUSINESS NAME Terraphase Engineering Inc. ATTENTION Daren Roth <br />MAILING ADDRESS <br />1404 Franklin St, #600 <br />PHONE 510-645-1850 x38 <br />CITY <br />Oakland <br />STATE CA ZIP 94612 EMAIL daren.roth@terraphase.com <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERO <br /> <br />FACILITY/BUSINESS 0 <br />REQUESTORE <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 STAND ARDS 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 HE ALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) Daren Roth SIGNATURE <br />TITLE <br />Senior Project Geologist <br />Tax ID# <br />FA #: FAO 02_47 7 5 OWNER ID #: Dit)60 2a3 SC:f 4.- ACCOUNT #: A 46,) L[6 S 75-- ASSIGNED TO: <br />PR #: 7Ras-436. zl ACCOUNTING COMPLETED BY: <br />§ <br />DATE: <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUES # INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 Sla 114 II I- "X g i 6 I 1 4Z-Likil cl Li (-;; <br />Site Mitigation MFR 2-26-2018