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San Joaquin County Environmental Health Department <br /> DATEMASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 8125/14 � <br /> SITE MITIGATION& LOP <br /> $t—ADEO ARDOR EH D URe ONLY OWNER ID# - CASE# UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOWING PROPERTY OWN ER INFoRMArlow CREcxx OWNER CURRENTLYONFxEW7TN EH <br /> PROPERTY OWNER NAME (510)245.4423 <br /> First +u4__ <br /> Lasr PHONE NUMBER <br /> BO°1NEDtN""1° Best California Gas Ltd., PTP in standing of Phillips Petroleum Co. EMAI`ADDRErg <br /> sharon.e.evans 66.com <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Add"" 13116 Imperial Hwy <br /> Malting Address City State Zlp <br /> � Santa Fe Springs CA 90670 <br /> CORPORATION El INDIVIDUAL❑ PARTNERSHIP FEDAOENCYD OTHER El <br /> I <br /> SITE MITIOATIONEIENVIRONMENTAL ASSESSMENTUVOLUNTARY CLEANUP 0 WATER QUALITYLIHW PIPELINE INVESTIGATION LOP <br /> 1 <br /> FAoIUTYID# INV# AccourlrlD PR#tR0# AsaIONEOEMPtorEE LEnDAOENOEHO Y: ✓ RWQCB DTBC EPA_ <br /> 1227 - Vicki McCartney 1 <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEwTYPE of regulated Business? YES [I No <br /> SUSINE°°IFACILm/SiTENAME 7-eleven <br /> SITEADDRrsa 7647 Pacific Avenue SurrE# EURINE°SPHONE <br /> 209 476,8669 <br /> c'TM Stockton CAE ZIP 95207 <br /> BOARD OF SUPERvisOR DI°TRIOT LOCATioN CODE KEY1 KEY2 , <br /> Mailing Address 1fO/FFERENTfromFecllllyAddress AttenUon:orCare Of(optlonal) <br /> Mailing Address City STATE ZIP <br /> SIC CODE _j[APN# - COMMENT: - <br /> 077-480-14 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different fr-o/nProperty Owner or Facility Operator identified above. <br /> DUSINEea NAME Cardno ATC Attention:or Care Of(optlonag <br /> Mailing Address 1117 Lone Palm Avenue, Suite 201 B PHONE(209) 579.2221 <br /> crry ------- - -- CA ZIP 95351 <br /> Modesto <br /> AccayA"DDBESS for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AL'KNOWLeucsIENT: 1,the undersigned Applicant,certify that I am the Ower,Operator,or A+uhorlred Agent of this Business,and I acknowledgethat all PF.RARr Fb'E1', <br /> Psxer.77r•_s,FA,FoRc'EbtENTCNARGrs andlor ROURn'CHARGES assoelated with this operation will be billed to meat the address Identified above as theAccogyrADDRtSs for this site. I also certify that <br /> all intbrmaflon provided on this application Is true and correct;and that all regulated netiOtles will be performed In accordance with all applicable SANJOA019N COtIN Y Ordinance Codes and/o• <br /> Standards and STATE andtur FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at the abos facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessor stat infonnation to SAN JOAQUIN COUNTY ENVIRONAWNTAL IIF,ALT11 DEP.A IF 'as soon ns it is a ailnblc n d a!the sane time it is <br /> provided tome or my representative, <br /> APPLICANT NAME(PLEASE PRINT) Genelle Martin SIGNATURE — <br /> TITLE Environmental Technician TAX 11)#460399408 <br /> Ap r—ed By Date _____� Accounling_OHIoe Proce_eeing Com leted8y Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED ElY WORK PLAN PE <br /> FEE:$ 1 <br />