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San .Ruin County Environmental Health Qiartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> 11 Nov 23, 2010 SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE7NEFOLLOw1NGPROPERTY OWNER INFORMAT/ow CHECK IF OWN ERCURRENT.YONFILE wirHEHDLl <br /> PROPENIYOWNER NAME NA I I NA ( ) 210-283-2000 <br /> First MI Last PHONE NUMBER <br /> BUSINEw NAME EMAIL ADDRESS <br /> Tesoro Companies Inc <br /> Owner Hostile Address <br /> 3450 South 344th Way <br /> city STATE ZIP <br /> Auburn WA 98001-5931 <br /> Owner MaII1nB Address <br /> Mailltg Address City State zip <br /> CORPORATIONEI INDIVIDUAL El PARTNERSHIP❑ FED AGENCY❑ OTHER❑� <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP__ <br /> FAcaITY ID# INV# AccoUNTID PR#/RO# ASSIGNED EMPLOYEE LEADACENcY:EHD_RWQCB DTSC_EP,1 <br /> lla4Q <br /> FACILITYFII.E C0MPLE7ETNEF0LLOwING BUSINESS/FACILITY/SITE/NFORMAT/ON: <br /> Is this a NEw Business LOCATION notpreviously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No El <br /> Is this an ExIST NG Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No El <br /> BUSINESSAFACILn1'ISDENAME Tesoro Fuel Terminal <br /> SnEADDRESS SUITES BusnasSPHONE <br /> 3003 Navy Drive 209-466-8800 <br /> Cm STATE zip <br /> Stockton CA 95206 <br /> BOARD OF SUP ERV EORDISTRICT I LDCAroNCGDE ( KEY1 KEY2 <br /> Meiling Address WDIFFERENTfrom FacWAddresa Attention:orCare Of(out/rNMI) <br /> Mailing Address City STATE zip <br /> SIC CODE APNI&K-02` COMMENT: <br /> 1 KK77 fCo <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUBINEBBNmE Attention:orCare Of (optional) <br /> Stantec Consulting Corporation Todd Brown <br /> Mailing Addnse PHONE <br /> 3017 Kilgore Road Ste 100 916-861-04 0 <br /> Cm Rancho Cordova CA 95670-6150 STATE zip <br /> ACFODNLADORf9B for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Ouwer,Operasor,or Authorized Agent of this Business,and 1 acknowledge that all PER,UITFEES, <br /> PENALTIES,E.N'FORCENEAV CHARGES and/or Housti CH4RCCs associated with this operation will be billed to me at the address identified above as the ACCOUATADDNEYS for this site. 1 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 SAN JOAQUIN COUNIT Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent ofthe property located at the above facilirylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COU TV VIRONMENTAL HEALTH DEPARTMENT as soon as it is available and al the same time it is <br /> provided to me Or my representative. / r�"F /nS- <br /> APPLICANTNAME(PLEASEPRINT) �e 0 �Ve /7/j, �/ BIGNATIIRE I./�aT+�. <br /> /1. TAx ID# � <br /> TITLE y-/ a ` <br /> App-Ya l B Data SOS AanoDnan omae Proneeein CompbbIt By Data <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BV WORN PLAN PE <br /> FEE: <br />