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SaLIquin County Environmental Hialth Avartment <br /> DATE MASTER FILE RECORD INFORMATION ggMFR" GREENFORM <br /> E:;: <br /> _ SITE MITIGATION& LOP <br /> SRW(6c)31UNIT IV <br /> BRAD_ FA EHp�_ OWNER ID# CAGE# f'A� <br /> 4 <br /> JR So3o <br /> OWNER FILE:COMPLETE TNEFOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CURREWTLYONrAEWTH EHD� <br /> PROPERTY OWNER NAME NA <br /> NA ( ) 210-283-2000 <br /> Fast Ml Last PHONE NUMBER <br /> BUSWEEENAME EHdMLADDRESB - <br /> Tesoro Companies Inc <br /> Owner Moms Ad;;. <br /> - <br /> 3450 South 344th Way �I <br /> DRr STATE zip <br /> Auburn WA 98001-5931 <br /> Owner Melling Address <br /> Mailing Address City Stats Zip <br /> CORPORATKNLI INDIVIDUAL[I PARTNERSHIP❑ ,F FED AGENCY❑ OTHER E. <br /> SRHMi,neATIOIJ_ENVIRONMENTALASBISSMENT_VOLUNrARYCLEANUP_WATFROVALITY HWIShpauNCINvelm ATON_Lop__ <br /> FAOILITYID# INV# ACCOUNTID PR tR0# ASSIGNED EMPLOYEE LEAD AGENCY:EN RWQCa DTSC_EPA_ <br /> doll 22453 3(04 ( �fl I lir' <br /> FACILITYFII.E COMPLETE THEFOLLOW/NG BUSINESS I FACILITY/SITETWFORMATION.- --I <br /> Is this a New Business LOCATION notpreviously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No �+ <br /> Is this an EKIST NG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSIHESS/FACRm ISRE NAME Tesoro Fuel Terminal <br /> BREADDRWs SUITE# BUSINESS PRONE <br /> 3003 Navy Drive 209-466-8800 <br /> CRY <br /> Stockton CA 95206 STATE ZIP �t <br /> BOARDOF SUPEPV SORDISTRICT / LOCATOR CODE / KEYT KEY2 <br /> Mailing Address 1fC/FFERENT1romPS011*Address Attention:orCare Of(opf ane/f <br /> Mailing Address City STATE zip <br /> SIC CODE APN# COMMENT: <br /> Iy5-0zo _ of3 0654-Rtcc716n/5 d i -fa Da✓r7aal,L�.r�� <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identfedabove. <br /> BUSINESS NAME Attention:orCare Of(opHOluttl <br /> Stantec ConsultingCor oration Todd Brown <br /> Melling Address PRONE <br /> 3017 Kilgore Road, Ste 100 916-861-04TO <br /> CITY Rancho Cordova CA 95670-6150 STATE zip <br /> Awain7APOHP84 forfessaand Charge# OWNER FACILITY/BUSINESS THIRD PARTY BILLING anal <br /> Mllo'G AND COmRtuNeEACKNowt.EDGbENT: 1,the undersigned Applicant,orcul,that I am the Owner,Operator,or A.rhad adAgmt of this fbmmesq And I acknowledge that all PM,IIT£T;£B, <br /> PFK:II.TIPP,FNPoRCFAIPhTCNdFG£S and/or Horsa.r CH4R(aff Romdated wit,lick nperainn will be billed to mP at the address idenliGed above W the ACt 0f,%TADDREc9 for this site. I also eartify that <br /> ell mformatie.Provided an thin appGcadon is Ince and correct;and that ail regulated activities will be performed in accordance with all applicable SAN JOAQUIN C01cc Y Ordinance Codes amber <br /> Standards end STATE and/or FnERALLaws and Regulations. AT the undersigned owner,operator,or agent ofthepropem located at the above facility/site address,l hereby eutborize the release of <br /> any Rod all results sad ensireumentsl sssessment information to SAN JOAQUIN COU TY IRONMENTAL HEALTH DEPARTMENT as son.as it is available sad at the a..door it is <br /> provided to me or my representative. <br /> APPLICANT NAME PLEASEPRINT / /� // SlDxaruae ./✓;'YJi'/ 2 <br /> TITLE TAx ID# 7 <br /> Appreved By Data Acaountlre Orion Pr. IMT Completed B _ Data Z <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT <br /> PE <br /> PAYMENTTYPE RECEIPT# CHECK# RECEIVEDBY .WORN PION <br /> FEE:_ <br />