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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 1/23/2014 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDN CASE# UNIT IV . <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNEcKiFOWNERIs CURRENTLYONF/LEH9rm EHD <br /> PROPERTY OWNER NAME Phillips 66 Company (510)245-4423 <br /> FIRST MI LAST .PHONE NUMBER <br /> BUSINESS NAME Phillips 66 Company E-MAIL ADDRESS <br /> Evans,Sharon E cSharon.E.Evans@p66.com> <br /> OWNER HOME ADDRESS 1380 San Pablo Avenue <br /> CITY <br /> Rodeo STATE CA ZIP 94572 <br /> OWNER MAILING ADDRESS same as above <br /> MAILINOADDRESSCITY STATE zip <br /> ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY RESPONSIBLE PARTY ❑((--O--T��HER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP®WATER QUALITY LI77HW PIPELINE INVESTIGATION Jam(LOPO <br /> FACILITY 10# INV# ACCOUNT ID PR#1 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EH RWQCB TSC PA <br /> FACILITY FILE:COMPLETE BUSINESS I SITEI PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IN <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ® NO ❑ <br /> BUSINESSIFACILI7Y/SITEIPRtx1ECTNAME 76 Station#11192 <br /> SITE ADDRESS/PROJECT LOCATION 1403 Country Club Blvd. Su1TE# BUSINESS PHONE <br /> C"" 1P 95202 <br /> Stockton STATECAz <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPr/OVAL) <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 Cardno ATC ATTENTION:OR CARE OF.(OPRONAL) <br /> MAILINOADDRESS 1117 Lone Palm Ave Suite 201PHONE (209) 579-2221 <br /> CITY <br /> Modesto STATE CA zP 95351 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,AuthorizedAgent,or Responsible Parly and I acknowledge that all PER.tt/r FEES, <br /> PENALTIES,ENFORCEAMATCIzARCES and/or HOURLYCILMOEB associated with this project will be billed to me at the address Identified above as the ACCOUATADURESS for this site. I also certify that all i <br /> Information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUINCOUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.As the undersigned Onvrer,Operator,AntborizedAgen,or ResponsiblePartp for the project located above under facility/site address,I j <br /> hereby authorize the release of any and all results,reports,and other environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONNtEN[AL HEALm DEPARTAIENr as soon as It is available <br /> and at the same time it Is provided to me or my representative. +I <br /> APPLICANT NAME(PLEASE PRINT) Jeanne. Ho1T)sey SIGNATURE <br /> TITLECardno ATC - Consultant TAxID# 46- 399408 <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> 817E MITIGATION AMOUNT PATO DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE tI <br /> FEE:; <br /> I <br /> i <br />