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San Joaquin County Environmental Health Department <br /> « » GREEN FORM <br /> DATE 12/17/14 MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> CASE III -7,Z UNIT IV <br /> SHADED AR Fle FOR FHP USF ONLY OWNER ID# <br /> CHECKIF OWNER CURRENTLYONFILE WITH END <br /> OWNER FILE'COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION., (519 245.4423 <br /> PROPERTY OWNER NAME <br /> Rrst MI <br /> Lest PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME Best California Gas LTD Partnership in care of Phillips Petroleum Co. DC-17 sharon.e.evans@p66.com <br /> Owner Home Address <br /> STATE ZIP <br /> City <br /> Owner Mailing Address 13116 Imperial Highway <br /> State CA 7'P90670 <br /> Mailing Address City Santa Fe Spring <br /> PARTNERSHIP❑ <br /> FED AGENCY❑ OTHER El <br /> CORPORATION INDIVIDUAL❑ n <br /> SITE MITIGATION ENVIRONMENTAL ASSEESIMENTOVOLUNTARY CLEANUP WATER QUALITY 0 H PIPELINE INVESTIGATION D LOP t. <br /> ✓ RWQCB DTSC EPA <br /> INV# ACCOUNT ID PR#1 RO# ASSIGNED EMPLOYEE LEAD AGENCY:El D _ <br /> FAcamID# RO Vicki McCartney <br /> INFORMATION.' <br /> /FACILITY/SITE INFORMAT/ON <br /> FACILITY FILE COMPLETE THEFOL <br /> YES E] No <br /> Is this a Neva Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No <br /> Is this an EYJSTING Business LOCAnON but a NEW TYPE of regulated Business? <br /> BUSINESS/FACILrrY/SfTE NAME 7-Eleven <br /> SUITE# BU8INM PFIONE <br /> (209)476-8669 <br /> StreADDRESS 7647 Pacific Avenue <br /> CA 95207 <br /> zip 95207 <br /> Cm Stockton <br /> KEr2 <br /> BOARD OF SUPERVISOR DISTRICT <br /> v' Z LOCATION CODE b I KEY1 <br /> Attention:orCare Of(optional) <br /> Mailing Address KDIFFERENT from Facility Address <br /> STATE ZIP <br /> Mailing Address City <br /> COMMENT: <br /> SIC CODE APN# 077-480-14 <br /> THIRD PARTY BILLING INFO: <br /> Complete if Billing Party is different from Property Owner <br /> Attention:loltc Oeofr(Poroidj identified above. <br /> BUSINESS NAME C a rd no .579. <br /> PHONE 209 2221 <br /> ddres <br /> Mailing Address 1117 Lone Palm Avenue, Suite 201 B <br /> STATE CA zip 95351 <br /> CITY Modesto <br /> FACILITY/BUSINESS THIRD PARTY BILLING <br /> A TADDRESS for fees and charges OWNER <br /> UIN COUNTY Ordinance Codes and/or <br /> HofrRLYChe un 4 associated with this operation will t billed n meat the address identified above as the AcCoUN'AnDRESS for this site. I also certify that <br /> BILLING AND COMPLIANCE ACI:.NOW'LEUGMEffT; t the undersigned Applicant certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERAf1T FEES, <br /> PENAI,i 6S,ENFURC'EMENTCHARr;Et and/or <br /> the same time it is <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all apove plicable SAN JOAQ <br /> Standards and STATE and/or FEDERAL Laws <br /> rtndnRegf Regulations. <br /> s the undersigned JOAQI Nowner,operator,or agent of the ENVIRONMENTALrI FetLTHrty aDEP ted t R'TM'NT as aststooiotas rt�s a 4 I here 'authorize the release of <br /> anv and all results and environmental a. <br /> provided to me or my representative. SIGNATURE <br /> APPLICANT NAME(PLEASE PRINT) Genelle Martin TAx ID#460399408 <br /> TITLE Environmental Technician <br /> Date _--- <br /> AccoulrUng Ofllca Proce"Ing Cont low By <br /> A Proved B Ode CHECK# RECEIVED BY WORK PLAN PE <br /> RECEIPT# `�`Z6 <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE J J <br /> FEE:3 ----- ---- <br />