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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH D PARTMENT DATE 02/28/14 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SITE MITIGATION & LOP SHADED AREAS FOR EHD USE ONLY OWNER IDS CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/FOWNER/3 CURRENTL YON FILE W/7H EHD PROPERTY OWNER NAME #bWARd I Swto ) FIRST M/ LAST PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS 7-Eleven, Inc. OWNER HOME ADDRESS CITY STATE ZIP OWNER MAILING ADDRESS P.O. Box 711 MAILING ADDRESS CITY Dallas STATE TX ZIP 75221-0711 L'J CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITY 10# INv# ACCOUNT ID PR#J RO# � A88IGNfb EMPLOYEE w AGENCY&D RWQCB.�,,,-15TSC� PA_ 2 �1oSSS WOO4f , u FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ BUSINESSIFACILITYISITEMROJECTNAME 7-Eleven Store#20632 SITE ADDRESS I PROJECT LOCATION 4627 Da Vinci Drive SURE# BUSINESS PHONE CITY Stockton STATE CA ZIP 95207-6575 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OFr/OHAL) MAILING ADDRESS CITY STATE ZIP SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME 7-Eleven, Inc. c/o Stantec Consulting Services Inc. ATTENTION:ORCARE OF (OPTIONAL) MAILING ADDRESS PHONE 3017 Kilgore Road, Suite 100 916-861-0400 CITY Rancho Cordova STATE CA ZIP 95670 ACCOUNTADDRESSToSEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Relponvible Parr and I acknowledge that all PERAH7FEES, PENAL7/Ev,ENFORCEmEAT CHARGES and/or HOURLYCHARGE.S'associated with this project will be billed to meat the address identified above as the AC'COUNTAUDRESS'for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIryNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Danielle Manning SIGNATURE TITLE Project Manager, Stantec Consulting Services Inc. TAXID# APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTS CHECK# RECEIVED BY NFEE: N t 3