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San Juin County Environmental Health 6artment <br /> DATE 8 zo_12 MASTER FILE RECORD INFORMATION "MFR" <br /> GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FDR EHO USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWINO PROPERTY OWN ER lwom/A T1 w CHeGran OWNER CURRENTLYONF/LEW/nf EMD <br /> Pecipsam ONNER NAME SBS <br /> c/o PETRO INC. <br /> /o Au E Padda <br /> RO <br /> First MI Last PHONENUMBER 209-343-3233 <br /> BUSINESS NAME FLAG CITY SHELL ENAILAooRFee <br /> lakewoodchewyahoo.com <br /> Offner HDrDe Addreas 6437 W. Banner St. <br /> City Lodi STATE LP <br /> CA 95242 <br /> Owner Mailing Address 6437 W. Banner St. <br /> Mailing Address City Lodi state CA Zip 95242 <br /> CORPORATION® INDIVIWAL❑ PARTNERSHIP❑ FEDAGENOY❑ OTHER❑ <br /> Srre IItITIOATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY RW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID# INV# AcCOUNTID PR#IR( AGENCY:EHD--JVWQCB)(—DTSC_EPA_ <br /> JuNuu <br /> FACILITYFILE COMPLETE 7HEFOLLOW/NO BUSINESS/FACILITY/SITE/NFORMA71ow <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION bwta NEW TYPE of regulated Business? YES ❑ No S <br /> BUSINEsslFADILITYISITE NAME Flag City Shell <br /> SITEADDRESS 6437 W. Banner St. SUITE# BUSINESSPHONE <br /> CITY Lodi STATE 7Jp <br /> CA 95242 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE 2 KEY1 KEY2 <br /> Mailing Address KD/FFERENTADYn FwAllyAddYeea Atlentlan:orCare Of(opdonaIi <br /> Mailing Address City STATE ZIP <br /> SICOODE API# COMMENT: <br /> OSS-3Zr�-I <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME GIL MOORE OIL COMPANY Atbantlan:orCafe Of(opCanaif <br /> Mailing Addreae P.O. BOX 529 <br /> PHONE 916-714-9828 <br /> CIT' WILTON, CA STATE CA LP 95693 <br /> AgOglsf,4 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned ApptironU eertify that 1 am the Owner,OPeranR,or Awhorized Allem of this Business,and I acknowledge that all PERMII'FEES, <br /> PENACnES,ENFORCEMENT CHARGES and/or HoU UYCHAfv,9v associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRESS for this site. 1 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/she address,I hereby authorize the release of <br /> any and all result 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 ` \. • l <br /> TITLE PROJECT MANAGER <br /> TAX ID# T <br /> Approved 13Y AccouMing Otnce ProoessigCompleted By Data <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# RECEIVED BY WORK PLAN PE <br /> FEE:: CHECK# 29 S <br />