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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM 11MFRf1-GREEN FORM DATE 04/1 512 0 24 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/F OWNER/S CURR£NTLYON FILE WITH EHD PROPERTY Brad Wungluck PHONE 209-456-8562 OWNER NAME I FIRST MI LAST BUSINESS NAME City of Manteca E-MroLADorIEss bwungluck@manteca.gov OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPTIONAL) L.M STATE zip OWNER MAILING ADDRESS 1215 West Center Street,Suite 201 MAILING ADDRESS CITY Manteca STATE CA zip 95337 ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP Q GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ® ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2964 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 BUSINESS/FACILnY/SREIPROJECT NAME Yosemite Senior Housing Phase II ESA APN 217-210-100&217-210-110 SITE ADDRESS/PROJECT LOCATION 309 W.Yosemite Ave and 105 Sycamore Ave BUSINESS PHONE CITY Manteca STATE CA zip 95m BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEn MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILINGADDRESSCnY STATE CA ZIP SIC CODE COMMENT: REQUESTORIS INFORMATION: BUSINESS NAME Condor Earth ATTENTION Luke Castle MAILINGADDRESS 188 Frank West Circle,Suite I PHONE (209)536-7379 CITY Stockton STATE CA ZIP 95206 EMAIL Icastle@condorearth.com ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTORM BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, or Responsible Parry HAR with this project "411 be billed to me at the address identified above as the Ac-c-OuNfAftDRESS for this site I also certify that all 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 provided to me or my repres tative. APPLICANT NAME(PLEASE PRINT) Brad Wun luck SIGNATURE \'�z TITLE Deputy Director - City of Manteca TAXID# O y-G0003(p FA M OWNER ID M ACCOUNT#: ASSIGNED TO: PR M ACCOUNTING COMPLETED BY: DATE: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2903 523 $486.00 2904 523 $810.00 11 Site Mitigation MFR 2-26-2018