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SAN OQUIN COUNTY ENVIRONMENTAL HEALTHWARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> SHADED AREAS FOR EHD USE <br /> DATE Oct. 16, 2017 <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: <br /> CHECK/FOWNER/BCHRRENTLFONF/LEWTTH EHD rK <br /> PROPERTY Phillips 66 Company PHONE (510)245-4423 <br /> OWNERNAME /RST <br /> sr <br /> EMAILADDRESS <br /> BUSINESS NAME Phillips 66 Company St= .evanS@1266.com <br /> ATTENTION:ORCARE OF(OP710ML) <br /> OWNER HOME ADDRESS 1380 San Pablo Avenue <br /> CITY Rodeo STATE CA ZIP 94572 <br /> OWNER MAILING ADDRESS (same as above) <br /> STATE LP <br /> IMIu xG ADDRESS Cm' <br /> M CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY ❑RESPONSIBLE PARI/' ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ® RWQCB LEAD- ❑ RWQCB LEAD- ❑ DISC LEAD El FED EPA]LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE AC TION WATER QUALITY(W DR) 2959 2954 <br /> 2950 2953 29601352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> ISTHIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESWIFACILIIYISITEIPROJECT NAME 76 Station APN. 104-160-04 <br /> ITE ADDRESS I PNOJECT LOCATION BUSINESS PHONE <br /> S <br /> 1206 E. March Ln. <br /> c" Stockton STATE CAPP 95210 <br /> BLNRDOFSUPERVIWRDISTRICTLWATION CODE KEY1 KEY2 <br /> MAILING ADDRESS.IF DIFFERENT FROM FACILITY ADDRESS <br /> STATE ZIP <br /> MAILING ADDRESS CITY <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATC Group Services LLC ATTENTION:ORCARE OF(CPTWNALJ <br /> muNGADDREsePHONE 209-579-2221 <br /> 1117 Lone Palm Avenue, Suite 201B <br /> Cm Modesto STATE CA ZIP 95351 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Party 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 ACCOUNTADDRESS for this site.I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address,I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or representat) C. <br /> APPLICANT NAME(PLEASE PRINT) JeanneHornsey. - SIONATUR � <br /> TITLETUID# 46- 399408 <br /> ATC Group Services- Consultant <br /> ACCOUNTS: Q N� ASSIGNEDTO: <br /> FAM: do� OWNER ID M:O/" <br /> PR#: -iizo ACCOUNTING COMPLETED BY: DATE. / 7 <br /> SR TYPE PE SC FEE INFO MT REMITTED CHECK# RECV'D BY DATE I SERVICE R,E/QUUEESTTF INVOICE# <br /> Work Plan 2903 523 $456.00 <br /> 2904 523 $760.00 07 <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />