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1 <br /> San jWuin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# F UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/AKiPROPERTY OWNER INFORMATION. CHECK/F OWNER CURRENTLYONF/LEW/TN EHD ❑ <br /> PROPERTY OWNER NAME Port of Stockton PHONE (209) 946-0246 <br /> First MI Last <br /> BUSINESS NAME Port of Stockton SGCSEC/TAx ID# 94-6001403 <br /> Owner Home Address 2201 W. Washington St. DRIVER'SLICENSE# <br /> City Stockton STATE CA ZIP 95203 <br /> Owner Mailing Address P.O. Box 2089 <br /> Mailing Address City Stockton State CA Zip 95201 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No ❑ <br /> IS this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILRYISITENAME NuStar Operations Partnership L.P. <br /> SITEADDRESS 2941 Navy Drive SUITE# BUSINESS PHONE(2 0 9) 943-51 62 <br /> CITY Stockton STATE CA ZIP 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 <br /> Mailing Address KDIFFERENTfromFacIWAddress Attention:or Care Of(option,/) <br /> Mailing Address City STATE ZIP <br /> SIC CODE <br /> �FAPN# COMMEhfT: <br /> THIRD PARTY BILLING INFO: Complete ifBil ling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> AccouNTADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMEAT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRESS for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SA.N JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facgity/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE=NT it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANTNAME James Neal PLEASE PRINT SIGNATURE <br /> TITLE Compliance Specialist (WGR Southwest, Inc.) DRIVER'S LIC E# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Data Accounting Office Processing Completed By Date <br /> 29-02 I0i12%07 MASTER FILE RECORD-GREEN <br />