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ok.0 <br />SITE MITIGATION MASTER FILE RECORD INFORMATION RW4> <br />"MFR"- GREEN FORM <br />DATE September 14,2018 /-41:44V194, EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CflECIOVrnER,gCURRENTEYON4DIII <br />ilk, At <br />PROPERTY <br />OWNER NAME <br />PHONE <br />440-288-1122 Finsr MI Lnsr <br />BUSINESS NAME Vertiv Group Corporation E-MAIL ADDRESS <br />OWNER HOMEADERESS 1050 Dearborn Drive ATTENTION: ORCARE OF (OPTIONAL) Jacob Watson <br />Car Columbus STATE OH ZIP 43085 <br />OWNER MAILING ADDRESS 1050 Dearborn Drive <br />hut LING ADDRESS CITY Columbus STATE (-)H ZIP 43085 <br />[1: CORPORATION Li INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY n RESPONSIBLE PARTY E OTHER <br />1:1 ENVIRONMENTAL EBB LOCAL VOLUNTARY RWQCB LEAD— El RWQCB LEAD- <br />WATER QUALITY (WDR) <br />2965 <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />In DISC 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 0 <br />YES [1] No 0 <br />BUSINESWEACILM/SITE/EROJECT NAME APN <br />SITE ADDRESS/ PROJEOT LOCATION 705 North Carlton Avenue BUSINESS PHONE <br />CITY Stockton STATE cAZIP 95203 <br />BOARD OF SUPERVISOR DISTRICT ..'...,:, LOCATION CODE KEY1 KEY2 —1 <br />MAIL NG ADDRESS , IF DIFFERENT FROM FACIUTY ADDRESS 1050 Dearborn Drive <br />MAILING ADDRESS CITY Columbus STATE 0 HZIp 43085 <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br /> <br />BUSINESS NAME Vertiv Group Corporation ATTENTION Jacob Watson <br /> <br />MAILING ADDRESS 1050 Dearborn Drive <br /> <br />PH"E 734-417-8071 <br /> <br />CITY Columbus STATE OH <br />ZIP 43085 EMAIL • )acob.watson@vertivco.com <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERE <br /> <br />FACILITY/BUSINESSE <br /> <br />REQUESTOR2 <br /> <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the nndersigned 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 ORDLNANCE 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 •ep -esentative. <br />APPLJCANT NAME (PLEASE PRINT) Ken Baughman SIGNATURE <br /> <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />TITLE VP/GC, Real Estate for Vertiv Group Corporation <br /> <br />Tax 11://i <br /> <br />FA #: r <br />; <br />OWNER ID #:' ACCOUNT N: 4g:664...,4, ASSIGNED TO: <br />PR ($: :-V161 ACCOUNTING COMPLETE° BY: DATE: <br />1—SR TYPE PE SC FEE INFO AMT REMITTED CHECKit RECY'D BY DATE SERVICE REQUEST4 INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 ti(iti'"iii IA, f 4'4, ,iitiii;iitiL.1:,.‘i <br />Site Mitigation MFR 2-26-2018