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. F <br /> San Julluin County Environmental Health 60artment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> -12' SITE MITIIGATION& LOP <br /> 8 SPGR EHD ON D/ �D�'H_f ? � CDASE&��O� UNIT 'V <br /> OWNER IDf 111 TIOJ JK (yp�p <br /> OWNERFILE:COMPIETE7tlEF0110wtNGPROPERTYOWNERINFOkNd CHecrrOWNERCuaRENrzyoxF/eeNyrwEHDEl <br /> SBSJ PETRO INC. SRco J�Cr(D / 1 <br /> PROPERNOWNERNAME c/o Rupi Padda ` / <br /> —First-- -- -MI— ----- --Last- - - - -PHONENUMSER-209-343-3233 <br /> BUSINESSNAME I EMAILADDRESS <br /> FLAG CITY SHELLlakewoodchevolyahoo.com <br /> Owner Home Address 6437 W. Banner St. I�tJL� <br /> City STATE ZIP <br /> Lodi CA 95242 <br /> Owner Mailing Address 6437 W. Banner St. <br /> MeilNlg Address CRY Lodi Sfeta CA Zip 95242 <br /> CORPOMTION[a INDIVIDUAL❑ PARTNERSHIP❑ ran AGENCY OTHER❑ <br /> SITE MITIGATION%ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID It INVA Accounr lDP1 RO I ASSIGNED EMPLOYEE LEAo AGENCY:EHD_RWQCB�DTSC_EPA <br /> $"7-7 7v 1 b 5 SZ 1.3 L� JOHuu <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No El <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YEs ❑ No In <br /> BUSINEWFACILRY/SITE NAME Flag City Shell <br /> SREAODRESS 6437 W. Banner St. SUITE# BUSINESS PHONE <br /> CITYLodi STATE ZIP <br /> (] CA 95242 <br /> BOARD OF SUPERVISOR DISTRICT L/ LOCATION COOS L NEY1 NEYZ <br /> Mailing Address/fDIFFERENTirwcFac#*Addrant Atbentilcm:o are Of(optfdrmy) <br /> Mailing Address CRY STATE Zip <br /> SICOODE APNNT I COMMENT: <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party is different from Property Owner orFacility Operator identifiedabove. <br /> BUSINESSNAME GIL MOORE OIL COMPANY Attention:/ Care Of(optlonasp <br /> Mailing Address P.O. BOX 529 PHONE 916-714-9828 <br /> CITY WILTON, CA STATE CA Zip 95693 <br /> AIXXg/A�ADORFGC forfeestud charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMPFEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that <br /> 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 <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) TIMOTHY J. CUELLAR SIGNATURE rV,r,EJy <br /> TITLE PROJECT MANAGER TAXID—#—� <br /> L <br /> Approved By Dote Accounting DISce Processing Completed By Date <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT/ CHECKK RECEIVED BY WORN PIAN PE <br /> FEE:$ <br />