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SAN.1...,1UIN COUNTY ENVIRONMENTAL HEALTH "....'ARTMENT <br /> 04/29/14 " GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR» <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDN CASE* UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTL Y ON FILE WITH EHD <br /> PROPERTY OWNER NAME ( ) <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> 7-Eleven, Inc. <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS P.O. Box 711 <br /> MAILING ADDRESSCITY Dallas STATE TX ZIP 75221-0711 <br /> ©CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY IDS INV# ACCOUNT IO PR RO N ASSIGNED EMPLOYEE JLEAD AGENCY:EHO X RWt C8 <br /> ROM / fN 7777t <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESSIFACILITY/SITHPROJECTNAME 7-Eleven Store#17334 <br /> SITE ADDRESS I PROJECT LOCATION 4501 North Pershing Avenue SUITES BUSINESS PHONE <br /> Cm Stockton STATE CA ZIP 95207 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE / KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPrlomt.) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME 7-Eleven, Inc. c/o Stantec Consulting Services Inc. ATTENTION:ORCARE OF(OPYWML) <br /> MAILING ADDRESS PHONE <br /> 3017 Kilgore Road, Suite 100 T916-861-0400 <br /> CITY Rancho Cordova STATE CA zip 95670 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> 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, <br /> 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 <br /> 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 <br /> 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 <br /> 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 <br /> and at the same time it is provided to me or my representative. ` <br /> APPLICANT NAME(PLEASE PRINT) Debbie Lichtenberger SIGNATURE <br /> TITLE Environmental Tech/Permit Coord., Stantec Consulting Services Inc. TMIDN <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTS CHECK# RECEIVED BYl 6ki 'l <br /> N Y �, <br /> FEE: <br /> } r, :ar' <br />