Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 7/22/14 <br /> DATE11 1 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> ' <br /> SITE MITIGATION&LOP <br /> StlAOE(3AREA9 FOR EHD USE ONLV OWNER ID# CASE# SJCEHD#1039 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK/F OWNER/3 CURRENTL Y ON F/LE W/TH EHD <br /> PROPERTY OWNER NAME Dave Patten (925) 790-6581 <br /> FIRST MI I LAST PHONE NUMBER <br /> BUSINESS NAME Chevron Environmental Management Company E-MAILAODRESS <br /> dr atten@chevron.com <br /> OWNER HOME ADDRESS <br /> 6101 Bollinger Canyon Road <br /> CITY STATEZIP <br /> San Ramon I CA 94583 <br /> OWNER MAILING ADDRESS <br /> 6101 Bollinger Canyon Road <br /> MAILING ADDRESS CITY STATE CA ZIP <br /> I San Ramon STATE <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_X_ENVIRONMENTAL ASSESSMEN_VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION—LOP_X_ <br /> FACILITY ID# INV# AccouNTID PR#IRO# ASSIGNED EMPLOYEE LEADAGENCY:EHDX RWQCB_DTSC_EPA_ <br /> 'f06O7700391 Vicki McCartney <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No [� <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> BUSINESS/FACILITYISITEIPROJECTNAME former Chevron former Service Station#9-0557 <br /> SITE ADDRESS I PROJECT LOCATION SUITE BUSINESSPHONE <br /> E 139 South Center Street <br /> 1 <br /> CITY Stockton STATE CA'"' <br /> i <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPT/OVAL) <br /> Same as Responsible Part <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME AECOM Attention Jessica Law ATTENTION:ORCARE OF OPTIONAL) <br /> MAILING ADDRESS PHONE <br /> 901 Via Piemonte,Suite#500 (909) 579-3981 <br /> CITU STATE ZIP <br /> Ontario CA 91764 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINGE <br /> RtI.I.ING AND COMPLIANCE ACKNOWLEDCAIEN'T: 1,the undersigned Applicant,ccrlify that him the(Arno,OperrrGir,,1 rd/mricerl agca/,ar Responsible Purh,and I aclmmrledge that all PL-l61Ill'FEES, <br /> PENALTIES,E,'tTORCE,UtiA'TCH tItGES nod/or 11ouRuOmR(xy associated nvilh this projeel will be billed to meal the address identified abnre as tine ACCOLINI'APDRESS for this site. I also certify Thal all <br /> information provided oil this application is h-ue and correct;and that all regulated acthitics trill be performed in accordance tt•ilh all applicable SAN JOAQUIN CO LN OKDINANCE CODES and/m• <br /> STANDARDS.Ind SI'A'fE and/o•FEDERAL Lairs and REGULATIONS. As the undersigned Mwier,Operator,Andiariccd efgenl,or Respons'i/de Atr(i,for the pruiect located ahm•e under Ncilil)/site address,1 <br /> hereby aulhorim the release of any and all results,reports,:ntd other enriroomenlal nsscssurcnl infm•malion to S AN JOAQITIN Cotwry ENN'IRO."IENTAL Iir.AGI Il DEPAR'TAIENT as Irma as it is nvnilabic <br /> and at the same time it is provided to me or my represenlalite. <br /> APPLICANT NAME(PLEASE PRINT) Alo I1'Lo Poach SIGNATURE <br /> TITLE Project Geologist,APCOM (oil behalf of Climorl ENIC) TAxID# 61-1088522 <br /> APPROVED BY DATE ACCOUNT114G OITICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DAIS OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BV WORK PLAN PE <br /> FEED _. _ _.. .___—.—____ <br />