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SAN JOA 'N COUNTY ENVIRONMENTAL HEALTH r 6,RTMENT <br />SITE MITIGA ION MASTER FILE RECORD INFORION FORM <br />"MFR"- GREEN FORM <br />SHADED AREAS FOR EHD USE f, DATE <br /> 7/18/18 <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION.' CHECK IF OWNER 18 CURRENTLY' ON FILE WITH EHD <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 (OPT/ONAL) <br />Crry STATE Manteca CA ZIP 95337 <br />OWNER MAILING ADDRESS Same as home address <br />MAILING ADDRESS CITY STATE ZIP <br />11 CORPORATION <br /> 0 INDIVIDUAL <br /> 0 PARTNERSHIP <br /> El GOVERNMENT AGENCY D RESPONSIBLE PARTY <br /> 0 OTHER <br />ENVIRONMENTAL 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 />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 0 No ZI <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES CgJ No El <br />BUSINESS/FACILITY/SITE/PROJECT NAME APN Previous Site Address/Name: 453 Moffat Blvd 221-090-200 <br />SITE ADDRESS! PROJECT LOCATION <br />400 E Yosemite Ave <br />BUSINESS PHONE <br />Crn, Manteca STATE ZIP CA 95336 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil KEY2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br />BUSINESS NAME Terraphase Engineering Inc. ATTENTION <br />Daren Roth <br />MAILING ADDRESS <br />1404 Franklin St, #600 <br />PHONE <br />510-645-1850 x38 <br />Cm( <br />Oakland <br />STATE CA ZIP <br />94612 <br />EMAIL daren.roth@terraphase.com <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OVVNERIII <br /> <br />FACILITY/BUSINESS0 <br /> <br />REQUESTORD <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 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 #: 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 Han 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 <br />Site Mitigation MFR 2-26-2018