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San Joaquin County Environmental Health Department <br /> DATEt- 2-7-tI 9 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHADED AREAS FOR EHD USE ONLY Datum IDX CAM UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOwwo PROPERTY OWNER/NFORMAT/ow CRECRIF GW ER CURRENTLY ONFKE MTN END <br /> PROKErnC VNERNAME 7-Eleven, Inc. PHONE <br /> First MI Last <br /> BusmEw NAME Same _ �,. AY 1924 Sac SEC/TAE ID# <br /> Owner None Address f722RouthStreet ORNER's LICENSER <br /> city Dallas STATE TX zip 75201 <br /> ONI.r Mailing AaEraaa PO BOX 711 <br /> Meiling Addreascity Dallas state TX zip 75221 <br /> CASRPoRATbN® INDIVIDUALPARTNERSHIP❑ FEDAGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY IO# CROSS REF IDR � AOOOUNTID# INVR <br /> COMPLETE rwFoLLoww BUSINESS/FACILITY SITE AtFORtim now <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? VES ❑ NO El <br /> Is this an EXISTING BUSine"LOCATION but a NEW TYPE of regulated Business? yes 91 No ❑ <br /> BustNEss/FAORITY/SIrENAIE 7-Eleven Store#14113 <br /> SITEADDREss 3040 West Benjamin Holt Drive SDITEX BUSINESSPHONE 478-3040 <br /> c- Stockton, CA STATE zip 95219 <br /> SOAROOFSUPERIISORDISTRICT LOCATION Com KEY1 KE 2 <br /> Meiling Address NOrFFERER thSnFec1WAddress Attention:w Care Of topUone/J <br /> 3017 Kilgore Road, Suite 100, Rancho Cordova, CA 95670 C/O Stantec Consultinq Corporation <br /> Melling Address City STATE ZIP <br /> SIC CODE APN III MENT: <br /> THIRD PARTY BILLING INFO: Cpmpfiiiete'i(Billing Party is diff rt from Property Owner orFacili`y Operator identified above. <br /> BUMNESS NAME Attention:arcane Of fopHana) <br /> Malling Address 3017 Kilgore Road, Suite 100, Rancho Cordova, CA 95670 PHONE 916-861-0400 <br /> cltt STATE ZIP <br /> AlooyyrAOQRE$S for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANI'F AORNDWLSW..MONI': 1,eu untlerxi(;nell Applkan1,certify that I am the(MR",(h+uatnq or ARMnr1,rJ:fgenl of this Business,And I acIUII lkdpe.Ihnl all PooRn'FEFti <br /> Iks',unFS,IiN"Vxt."Ay(il UdRY Amuor I/OURI.Y C7UxncP asv.inleJ..ith thin.lunation will be billal to meat the undress idmfified abat,nv the AMmVI A,UtM..y for Ibis site. I oho nrfifv that <br /> all inhnmatimi provid.1 ms Poi,apPlieufion is ave and sansei;and that all n,,.I.ed wwiti.Pill IM I.rfornral in nemndance Nidi u11 applicable SAN JOAQUIN COUNTY Ordinance(Imlo and/or <br /> Standanls mW NNA If,ami/or FEltv"I,Laws anll Regnladons. As n.underMRnetl o.tnr,operntor,or aamt of the Prop"leraal at the above fiad ity)site AJdruwv,I hereby amhuliu the nrlease of <br /> and all r,,al.and mvirnnmmtal..U.,infnrmafion tR SAN JOAVUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as anon w it in avnilaflle and a the same fin.it is <br /> pnovined m R.army representafiVc <br /> PLEASE PRINT <br /> APPLICANT NAME Damon Brown SIGNATURE <br /> TITLE DRIVER'S LICENSE N <br /> Geologic Associate, Project Manager (PHOTOCOPY REQUIRED) <br /> Approved sY Date Accoun0n90ffice Procesvng Completedey Date <br /> N-02 I DI R•OT MAS I FR FILE RECORD`GRF.LN <br /> i �► <br />