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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE 12/16/13 M, 'ER FILE RECORD INFORMATION R" GREEN FORM SITE MITIGATION & LOP SHADED AREAE FOR EHD USE ONLY OWNER ID* CASE* UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER isCURRENTLYONFILE wITH EH El PROPERTY OWNER NAME Mark Lill (209) 944-5613 ext.12 FIRST Inc. MI LAST PHONE NUMBER BUSINESS NAME William ,I s Tanks Lines, nE-MAIL ADDRESS OWNER HOME ADDRESS 1477 Tillie Lewis Dr. Cm Stockton STATE CA LP 95206 OWNER MAILING ADDRESS SAME AS ABOVE MAILING ADDRESS CITY SAME AS ABOVE STATE LP ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPONSIBLE PARTY ❑OTHER SITE MITIGATION__ENVIRONMENTAL AMsEESMENT_VOLUNTARY CLEANUP X WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID* INv* (�pA�CCODUNNT(�I,DI PR*/RO* LNED EMPLOYEE LEAD AGENCY:EHD-(_RWQCB_DTSC—EPA f f )b qz� 7�NJ�lI 1`f� �(�o537q�39/HENDERSON 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 BUSINEsa/FACILITY/SITE/PROJECT NAMEWILLIAMs TANK LINES FUEL TANKER SPILL SITE ADDRESS/PROJECT LOCATION 227/�34 E.MARIPOSA ROAD SURE* BUSINESS PHONE FCITY ESCALON STATE LP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 11244 PYRITES WAY ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY GOLD RIVER STATE LP 95670 pqY SIC CODE APN* COMMENT: �/V D JAN F THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY ID I ABO om, NV/ JlN BUSINESS NAME APEX ENVIROTECH,INC. ATTENTION:ORCAREOF (OPT70NALJl�/�T/�QNM�C�UN MAILING ADDRESS 11244 PYRrrEs WAY PHONE Cm GOLD RIVER STATE ZIP 95670 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCF ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Party and 1 acknowledge that all PERMrrFEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated 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 information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQtnN 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 JOAQUIN COUNTY�NviRONMELTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) I(�[i4.l Ua.l1 C(.4,C,&' SIGNATURE TITLE GO i97 TAx ID* Sr /, 36 q�-7 APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY 0 V L / DATE SITE MITIGATION AMOUNTPAID ff1)ATEF PAYMENT PAYMENT TYPE RECEIPT* CHECK* RE CEIVEED BY WORK PLANNPE FEE::375 I I I V ��) l/1,>