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San Joaquin County Environmental Health Department <br /> DATE "MFR') <br /> GREENFORM MASTER FILE RECORD INFORMATION MFR 1I <br /> 9NppFp AREAS FOR EHD D OWNER ID# I UNIT IV <br /> J.poo DQ,r2 CARE# <br /> OWNER FILE <br /> COMPLETE THE FOL LOW/NO PROPERTY OWNER/NFORMArtON.- CHECK IF Ow ER CURREN)LYONF/LElwrH END <br /> PROPERTYOWNERNAME 7-Eleven, Inc. <br /> J PHONE <br /> first MI Last <br /> BUSRIESSNAME Same ._ J r ; <br /> 44 S03SECITAxID* <br /> Owner Home Address 22 Routh Street <br /> DRIVER'S LICENSE# <br /> city Dallas <br /> STATE TX zip 75201 <br /> Owner Maillna Addreea PO Box 711 <br /> Mailing Address City Dallas <br /> State TX ZIP 75221 1 <br /> CORPORATWN® INDMPUAL❑ <br /> PARTNERSHIP El <br /> FED AQENLY❑ OTHER❑ <br /> `D FACILITY FILE <br /> FACILITY ID# 1 I1ld � ��� CRo58 PER ID# ACCOUNT ID# <br /> A�,nn�4i a tNv# 18-1 z� <br /> COMPLETE rHEFOLLOW/NGB SINESS/FACILITY/SITE/NFORMA wm <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPT.? Yu ❑ NO 29 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ® No <br /> BUSWESBIFAOIUTYISITENAw 7-Eleven Store#14113 <br /> $ITEAOOREw 3040 West Benjamin Holt Drive <br /> $URE# BUSINESBPHONE 478-3040 <br /> cm Stockton, CA STATE zip 95219 <br /> BOARD OF SURE VISOR DISTRICT LOCATION CODE i(EY1 KSr2 <br /> Melling Address BD*FERENrtfv nFao/JXyAOd/esa Attention:or Care Of <br /> 3017 Kilgore Road, Suite 100, Rancho Cordova, CA 95670 faP " <br /> Stantec Consult q <br /> C/O ng Corporation <br /> Mailing Address City <br /> STATE ZIP <br /> SIC CODE APN# <br /> THIRD PARTY BILLING INFO: Complete/i(ffBilling party is diN er.tfromPTOperiy Owner orPacility Operator identifiedabove, <br /> BUSINESS NAME <br /> 5-4'k�� /1.'f PC cO'.'VVV Sw(}:I�� �olP d,itl a-. Attention:Cross Of fopNona9 <br /> Mailing Addrese 3017 Kilgore Road, Suite 100, Rancho Cordova, CA 95670 PHONE 916-861-0400 <br /> Orr <br /> STATE ZIP <br /> AccOv�r�O ggE*q forfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> ISYIanNe Atte(opIDUANtT ACXNnWLPAf.MFNI': L Ole undenignul Apidicanl,eeni(y that 1 am Rm f)xner,(1 erulnr,or:Ivlhnri,cr/a•rr <br /> /'F.M1'A1/Y£.5',(iA'/(IR('EAJI"XY'(//:ffl if S ARII/Ill//(IIIR/YC:/LIRti(:f NRll,a'i:llell N'1111111iY Illlerafillrl W iB be Illllell 111 mp pl lhf x1111reYY Illmllfcll ahnVef NS flN3il(Ik'!)//.4Y„I/)aRf.MS <br /> L <br /> Tllrlllr 15 NICi11N ✓NI (Cer IrV EA <br /> xll inElmmliun In S,idai on taus xpplicafiun k gree and aorrecR and tlm all r gulmed Ipaivilies will IH perfomasi in uemrdanae with all applicable SAN JOAQIII.N(:OUR I Onlinance(ales aR,1/,Ir <br /> Stmldarch and SIA rE andtar FEUER,U,lays a ml RgUurons. More undersignai xwner,nperulor,or ayenloflho properly looted of the xbnvx facility/site Nddreu,lhereby authmiz<thc rrlcase of <br /> :ury and it results and envinmmenml aesasmml informafian m SAN JOAGUIN COUNTY ENVIRONMENTAL f1EA1;I'll DEPARI'MEN'1'as soon aN it ie avnilahle anA al the yams PoIM it n <br /> Pnwidcd A.Ie or my reprH,nlAlive. <br /> APPLICANT NAME PLEASE PRINT <br /> Damon Brown <br /> SIGNATURE <br /> wM�N,$� <br /> TITLE <br /> _ Geologic Associate Project Manager DRIVER'S LICENSE I, <br /> /PHOTOCOPY REQUIRED! <br /> ApPed BY Data A---W,,9 Ofryoe Prxeeling Completed By 9 D <br /> 20-02 1(/112/0'1 Date <br /> MASTER F'ILS kEC'ORD-G'kEl&N <br />