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SAN.1...,1UIN COUNTY ENVIRONMENTAL HEALTH "....'ARTMENT 04/29/14 " GREEN FORM DATE MASTER FILE RECORD INFORMATION MFR» SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER IDN CASE* UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTL Y ON FILE WITH EHD PROPERTY OWNER NAME ( ) FIRST MI LAST PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS 7-Eleven, Inc. OWNER HOME ADDRESS CITY STATE ZIP OWNER MAILING ADDRESS P.O. Box 711 MAILING ADDRESSCITY Dallas STATE TX ZIP 75221-0711 ©CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ FACILITY IDS INV# ACCOUNT IO PR RO N ASSIGNED EMPLOYEE JLEAD AGENCY:EHO X RWt C8 ROM / fN 7777t FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ BUSINESSIFACILITY/SITHPROJECTNAME 7-Eleven Store#17334 SITE ADDRESS I PROJECT LOCATION 4501 North Pershing Avenue SUITES BUSINESS PHONE Cm Stockton STATE CA ZIP 95207 BOARD OF SUPERVISOR DISTRICT LOCATION CODE / KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPrlomt.) MAILING ADDRESS CITY STATE ZIP SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME 7-Eleven, Inc. c/o Stantec Consulting Services Inc. ATTENTION:ORCARE OF(OPYWML) MAILING ADDRESS PHONE 3017 Kilgore Road, Suite 100 T916-861-0400 CITY Rancho Cordova STATE CA zip 95670 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Onwer,Operator,Authorized Agent,or Respomvible Party and I acknowledge that all PERAUT FEES, PENALTIES',ENFORCEMEN7'CHARGES and/or HOURLTCHARGES associated with this project will be billed tome at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Oftwer,Operator,Authorized Agenl,or Responsible Pmvy for the project located above under facility/site address,I hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ` APPLICANT NAME(PLEASE PRINT) Debbie Lichtenberger SIGNATURE TITLE Environmental Tech/Permit Coord., Stantec Consulting Services Inc. TMIDN APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTS CHECK# RECEIVED BYl 6ki 'l N Y �, FEE: } r, :ar'