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San Joaquin County Environmental Health Cfpartment <br /> DATE 10/9/2014 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> - -- --_—_ SITE MITIGATION & LOP <br /> 1HADIDAREAB_i0R EHD uq�ONLY <br /> -OWNERI(3# - CAGE#— UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNERINFORMATION CF/ECKIFOWNER CURREAinYONFILEW/TN EHD <br /> PROPERTY OWNER NAME Phillips 66 Company (510245-4423 <br /> First M! Lasl PHONE NUMBER <br /> BUSINESS NAME Phillips 66 Company E-MAILADDRESS <br /> sharon.e.evans 66.com <br /> Owner Home Address 1380 San Pablo Avenue <br /> city Rodeo STATE CA z" 94572 <br /> Owner Mailing Address <br /> same as above <br /> Mailing Address City State zip <br /> CORPORATION PSI INDIVIDUAL C PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ _ENVIRONMENTAL ASSESSMENT_ _VOLUNTARY CLEANUP—WATER QUALITY HW PIPELINE INVESTIGATION_ LOP_ <br /> FACILITY ID LIN ACCOUNTID PR#/RO# AS3IGNED EMPLOYEE LEAD AGENCY:EHD_RW61C8DTSC <br /> FACILITY FILE COnffPLETETNEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No (Rj <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES JI No ❑ <br /> BUSINESSIFACILITYISITENAME former Thrifty Oil Company Site 172 <br /> SMEADDRESS 7647 Pacific Avenue SUITE# BUSINESSPHONE <br /> CITY Stockton STATECA <br /> zip 95207 <br /> BOARD OF SUPERVISOR DISTRICTLOCATION COD . I KEY1 K!_y2 - <br /> Mailing Address/fDIFFERENTfromFacllllyAddress Attention:orCare Of(optlonal) <br /> Mailing Address City STATE ZIP <br /> SICConE r APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINm NAME Cardno Attenifon:orCare Of(opUonal) <br /> Meiling Address PHONE <br /> 1117 Lone Palm Avenue, Suite 201 209-579-2221 <br /> COY Modesto STATE CA zip 95351 <br /> A=0LW1ADDRFss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLINGV) <br /> WILLING AND COMPI. E ACKN V EDta IEN'; I,We undersigned Applicant,certify that I mn fire Owner,Operator,ordnlllorkeelAgeet of this Husiuess,and f aclu:otiviedge that 1111 pERAF7r FEES, <br /> PENN,ac77Es,BnFoacee7ErvTCu�Irrces and/or HotmLT'CHARcra'associnted with this operafion will be billed tome at the address identified above as theACCOUATAUDssts for this site. I 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 Fill appiicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE mrd/or FEDERAL Laws and Regulations. As the undersigned owner,opernfor,or agent of tile property located at the above facility/site address,I hereby:authorize the release of <br /> nn,Y and all results And environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTH DEPARTAIE'NT As soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINO Jeanne Homsey SIGNATURE <br /> TITLE Cardno ATC-Consultant TAX ID# 46-0399408 Y <br /> 1 � <br /> A proved By Date Accounting Office Proceeelltg Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ <br />