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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 2/15/2019 SHADED AREAS FOR END USE <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CHECKIF OWNER is CURRENTLYONFILEWITH EHD <br /> PROPERTY PNONE <br /> OWNER NAME iRS7 M1 LAST <br /> BUSINESSNAME Glenn Springs Holdings E-MAIL ADDRESS <br /> OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPTIONAL) Roger Smith <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS P.O. Box 2148 <br /> MAILING ADDRESS CITY Houston STATE TX `P 77252 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAOENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EH LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑■ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 29601352613527 2965 <br /> FACILITY PILE:COMPLETE BUSINESS 1 SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No i❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES Q No ❑ <br /> BUSINESSIFACILITYISITFIPROJECTNAME Former Occidental Chemical Corporation - Lathrop Facility APN 198-180-05 <br /> SITE ADDRESS I PROJECT LOCATION 16777 Howland Road BUSINESS PHONE 209-858-2511 <br /> CITY Lathrop STATE CA`P 95330 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE zip <br /> SIC COOS COMMENT: <br /> REQUESTOR°S INFORMATION: <br /> BUSINESS NAME Arcadis US ATTENTION Scott Hackman <br /> MAILING ADDRESS 630 Plaza Drive, Suite 100 PHONE 916 786 7369 <br /> '"' Highlands Ranch STATE CO ZIP 80129 EMAIL scott.hackman@arcadis.com <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[] FACILITYIBUSINESS❑ REQUESTOR❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PERa71T FEES,PENALTIES,ENFoRCEA1ENT 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 COIiNTV 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 rovided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Scoa}lackinan SIGMA <br /> TITLE Principal Scientist T""'D' J� -0��-� GG-� <br /> FA M OWNER ID M 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 Plan 2903 1 523 $456.00 <br /> 2904 523 $760.00 <br /> Site Mitigation MFR 2-26-2018 <br />