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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM " MFR " - GREEN FORM DATE 3/3 /2023 SHADED AREAS FOR EHD USE OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION : CHECKIFOWNER /sCURRENTLYONFILEwIm EHD ❑ PROPERTY ASP/ RWM Properties LLC , R & B L uise 4nd Delta LLC PHONE OWNER NAME ,RST AST 925 - 674 - 8400 BUSINESS NAME Reynolds and Brown danap@reynoldsandbrown . com OWNER HOME ADDRESS 1200 Concord Avenue Suite 200 ATTENTION : ORCAREOF (OPT/ONAL) CRY Concord STATE CA ZIP 94520 OWNER MAILING ADDRESS Same as above MAILING ADDRESS CITY STATE ZIP ❑ CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ GOVERNMENTAGENCY ® RESPONSIBLE PARTY ❑ OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ® RWQCB LEAD - ❑ RWQCB LEAD - ❑ DTSC LEAD ❑ FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY (WDR) 2959 2954 2950 2953 2960/3526/3527 2965 FACILITY FILE : COMPLETE BUSINESS / SITE/ PROJECT INFORMATION : IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION , BUT A NEW SCOPE OF WORK? YES ® No ❑ BUSINEss1FAciLm1SITE1PRwEcTNAME Former Pilkington North America APN 198 - 120 - 120 SITE ADDRESS / PRoJECTLoCAnI 500 East Louise Avenue BUSINESS PHONE 925 - 674 - 8400 CITY Lathrop STATE CA zIP 95330 BOARD OF SUPERVISOR DISTRICT LocAnoN CODE KEY1 KEY2 MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY ' STATE zip SIC CODEIF COMMENT: REQUESTOR' S INFORMATION : BUSINESS NAME AdvancedGeo , Inc , ATTEMXW Brian Millman MAILING ADDRESS 837 North Shaw Road PHONE 800 - 511 -9300 CITY Stockton STATE CA ZIP 95215 EMAIL bmillman@advancedgeo . biz ACCOUNT ADDRESS TO SEND FEES AND CHARGES : OWNER ® FACILITY/BUSINESS ❑ REQUESTOR ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT : I , the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or Responsible Party and I acknowledge that all PERn1IT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated identified above as the ACCOUNT ADDRESS for this site. I also certify that all with this project will be billed to me at the address information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS . As the undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address , I hereby authorize the release of any and all results , reports , and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is, available and at the same time it is pr hided to me or my jeMsentative. APPLICANT NAME (PLEASE PRINT '1 ° �/f✓'I se.� SIGNATURE TITLE IF TAXID # -FFFA0 'F17 i FA #: sr 14001 OWNER ID # : i� ! C r ACCOUNT #: O Z� - �' ASSIGNED TO: r . PR #: L `i , �' ACCOUNTING COMPLETED BY: i V DATE : v FFLSRTYPE PE SC FEE INFO AMT REMITTED CHECK# RECV' D BY DATE SERVICE REQUEST# INVOICE# an 2903 523 $456 . 00 9/ � [ f h 2904 523 $ 760 . 00 7 V + � Site Mitigation MFR 2-26 -2018 / 0 Z ` b