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SAN J 'IN COUNTY ENVIRONMENTAL HEALTH D RTMENT <br /> SITE MITIGA ION MASTER FILE RECORD INFORN,AriON FORM <br /> "MFR"-GREEN FORM <br /> DATE SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURREArn Y ON FILE wrH EHD ❑X <br /> PROPERTY f IW,n PHONE 714-731-1050 <br /> OWNER NAME IRS7 S7 <br /> BUSINESS NAME EMAE uilon Enterprises LLC dba Shell Oil Products US ancDrea.win shell.com <br /> OWNER HOME ADDRESS ATTENTIOWORCAREOF(O"ONAL) Andrea Wing <br /> CITY STATE LP <br /> OWNER MAILING ADDRESS 20945 South Wilmington Avenue <br /> MAILING ADDRESS CITY Carson STATE CA z,P 90810 <br /> 91 CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ® RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <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 /> BUSINESSIFACILITY/SRE/PROJECTNAME Former Shell Service Station APN 167-150-310-000 <br /> SITE ADDRESS/PROJECT LOCATION 434 East Martin Luther King Jr Blvd. BUSINESS PHONE <br /> CITY Stockton STATECAZ'P 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE ConwreNr. <br /> REQUESTOR'S INFORMATION: <br /> BUSINESSNAME Wayne Perry, Inc. ATTENTION Miriam Urena <br /> MAILINGADDRESS 8281 Commonwealth Avenue PHONE 714-826-0352 <br /> CITY Buena Park STATE CA ZIP 90621 EMAIL murena@wpinc.com <br /> ACCOUNTADDRESS TOSEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, <br /> or Responsible Parts, and I acknowledge that all PERMIT FEES,PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all <br /> information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br /> applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br /> undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br /> authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my r9presentative. <br /> APPLICANT NAME(PLEASE PRINT-) M / � � SIGNATURE // r <br /> TITLE 1�n J.' �G! 10 ►v/I 61Elm- W P� TAxIO* GAS 2- <br /> FA <br /> FAM: /�/ OWNER IDM: 0Woo r I ACCOUNT/: � - ASSIGNED TO: <br /> PR III: 1�(j (J I ACCOUNTING COMPLETED BY: I DATE: / <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE REQUEST# INVOICE# <br /> 2903 523 $456.00 zz� <br /> Work Plan 2904 523 $760.00 7�+ ~+✓��{YI- �> ° ?J 7 <br /> Site Mitigation MFR 2-26-2018 <br />