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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 111/23/2014 MASTER FILE RECORD INFORMATION MFRfs GREENFORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR END INEONLY OWNER IDS CASE# :"J` 7o UNIT IV <br /> sl 06 <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNEomScOMWER/o CORRENTrowlesLEHATM END <br /> PROPERTY OWNER NAME Phillips 66 Company (510)245-4423 <br /> FIRST MI LAST PNONENUMBER <br /> BUSINESS NAME Phillips 66 Company E-MAILADDRESS <br /> Eamil.Sbamn E c5hamn.E.Ewns®pfi6.cam> <br /> OWNERHOMEAMRESS 1380 San Pablo Avenue <br /> CRY Rodeo STATE`AA Z'P 94572 <br /> GWNERMAILINDADDREss same as above <br /> MAILINGADDRESs CITY 8TATE ZIP <br /> M CORPORATION El INDIVIDUAL El PARTNERSHIP ❑GOVERNMENTAGENCY ❑RESPONSIBLE PARTY F-1 OTHER <br /> SITE MITIGATION 0ENVIRON111TAL ASSESSMENT OVOLUNTARY CLEANUP 0 WATER QUALITY Il HW PIPELINE INVESTIGATIONO LOPE] <br /> FACILITY ID Ixv# ACCOUNT ID PR# RO A6SIGNED EMPLOYEE LEAD AGENCY:EHD RWOCB TSC PA <br /> O. i7 .1eHNM7 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH OEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUTA NEW SCOPE OF WORK? YES 0 No ❑ <br /> SUSINEssIFAIIILRYISREIPRwECTNAME 76 Station#11192 <br /> SREAD1XUSSIPROJECTLOCATION 1403 Country Club Blvd. SUITE// BUSINESSPHONE <br /> Cm Stockton STATE CA ZIP 95202 <br /> BOARD OF SUPERVISOR DISTRICT 2— LOCATION CODKEY2 <br /> MAILINGADDRESS,IF DIFFERENT FROM FAcivry ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SICCOOE APNhl 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:ORCARE OF(OPTIONAL) <br /> MAILINGADDRESS 1117 Lone Palm Ave Suite 201 PHONE (209) 579-2221 <br /> CITY Modesto STATE CA ZIP 95351 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER FACILITY/BUSINESS THIRD PARTY BILLINGS) <br /> ➢ uROA C ANCEA 'N C EN: I,the undersigned APPlieanAeerth"our lam the Ouvcq Operafe"AnOmrludAgent or Resfouslhle Pari•and l acknowledge thnlall P£AINTFE£s, <br /> PEN.1477ET,RNFORCF.IIEA'TC//MGES m:d/or NOURLI'CILIRC£S ossarinled with fills project will be billed tome at the address Identified above as therlOODUNTA/1DAESS for(his She. I also certify That all <br /> Information provided on this..Plication Is true Said correct;and Nol ell regulated notivides will be performed In accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS Fnd STATE smaller FEDERAL Lars and REGULAnONS.As The undersigned Oliver,OpendoQ AulLadudAgeal,or Responsible Parry for Rha project located obese under facility/she address,l <br /> herebysmumi za the rat"Seaf.ny.ed a firesults,reports,and other environmental asscssmenf Information to SAN JOAQUIN COUNTY ENWROATTEN'AL HEALTH DEPARTMENT a soon as It it Available <br /> mad at lbs NT NAE It is m ma or a representative. t <br /> APPLICANT NAME(PLFASEPflINT) Jeanne HQmSey SIGNATURE (v�'1A-•.- /'—«t- <br /> „TLE Cardno ATC - Consultant TAXID# 46-6399408 <br /> APPpOVEOSY DATE ACCUDNING OfFICEPROSE6EING COMPLETEOSY DATE <br /> fi1TE MITIGATION AMOUNT PAID DATE OF PAYMENT PAVMENTTVPE RECEIPT# CHECK RECEIVED BY WORK PLAN PEE <br /> { ( 'Z(p <br />