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- -- -.— --_..-, _....._..... .. . .. .ass clura..rc.1, <br /> DATE 11123/2010 M TER FILE RECORD INFORMATION FFM FF GREEN FORM <br /> SITE UNIT <br /> & LOP <br /> SHADED ARMS FOR ENO ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE TNEFOLLOW/NG PROPERTYOWNER INFORMAT/ON.' CHEcKIF OWNER CURRENTLYONFaeNYrH EHD <br /> PROPERTY OWNER NAME <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME EJMILAOURESS <br /> TOC Holdings markchandler@tocholdings.com <br /> Owner Home Address <br /> 2737 West Commodore Way <br /> City STATE ZIP <br /> Seattle WA 98199-1233 <br /> Owner Mailing Address <br /> Meiling Address City state Zip <br /> CORPORATION® INDIVIDUAL El PARTNERSHIP❑ FEo AceNOY❑ OTHER[3 <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> # INv# ACCOUNTID <br /> FACILITYID ?PR IH R9M AaaIONEG EMPLOYEE LEAD AOENCY:EHD_RWQCB_OTSC_EPA <br /> _ <br /> ADD bo <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMAT/oN: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No [tyK, <br /> Is this an ExISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO E] <br /> BUSINESIUFACILm'/$ITE NAME Former Time Oil Terminal <br /> SiTEADONESS 3015 Navy Drive SURE# BUSINESS PHONE <br /> Cm STATE zip <br /> Stockton CA 95206 <br /> BOAROOFSUPERVISORDIarma LOCATION CODE KEyf KEY2 <br /> Mailing Address KOIFFERENThomFacN/fyAddrece Attention:Grown Of(oplbnaQ <br /> Melling Address City STATE ZIP <br /> SICCODE J APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> BUSINESS NAME Attention:at-Care Of( b'"l) <br /> Stantec ConsultingCorporation Ciodd Brown <br /> Malting Address PHONE <br /> 3017 Kilgore Road,Ste 100 916-861-0400 <br /> CITY Rancho Cordova STATE CA zip 95670-6150 <br /> Accouyr,sl—s for fees and charges OWNER FACIIJTylBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKN JWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Allen[of this Business,and 1 acknowledge that at,PEz T FEET, <br /> PENALTIES,ENFORCEMENTCHARGLS and/or HODFLYCHMGES associated with This operation will be billed to me at the address Identified above as the ARVyYYACnAFes far this site. I also certify that <br /> all information provided on this appgcadon ls true and emrecq and that all regulated activities will be performed in accordance with all applicable SAN JOAN UIN COUNTY Ord'mance Codes and/or <br /> Standards and STATE and/or FEDIBAL Laws and Regulations. As the undersigned owner,operator,or agent of the property looted at the above facility/site address,I hereby autho'¢q �se of <br /> any sad ail results and emhomrmsel assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aq scan a it u available ,r�-n�11�I1'R u <br /> provided to me or my repreenthm,s. V V1 <br /> APPLICANT NAME(PLEASE PRINT) gh0 Lvn SIGNATURE i' J-/ fT LL <br /> TITLE t,2 A`.I- CeO .SjV, ' TAx ID# — <br /> OUIN COUNTY <br /> it <br /> Approved By Case Anomntlng Orion Praceael.g Completed 8y Date TMCJE ` � <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BV WORKPLANPE <br /> FEE:.f <br /> a-Lr /f 6xv: F&-, -6M-4✓ 4z 69) Lf 6,6,-78o0 <br />