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SAN JOAQUIN COUNTY ENVIRONMENTAL HFALTHPPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"- GREEN FORM <br /> DATE 8/2/17 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CHECKIF OwHERYs CuRREHnrmnL wry EHD <br /> PROPERTY PHONE <br /> OWNERNAME FiRST ST <br /> BUSINESS NAME E ILADORESS <br /> Jacab Cor <br /> OWNER HOME ADDRESS ATTENTION:ORCANE OF faFTTORAL) <br /> CRY STATE LP <br /> OWNER MAILING ADDRESS <br /> 25460 South Schijite RnRd <br /> MAIDNDADDREBSCRY Tracy <br /> STATE CA aP 95377-9709 <br /> Q&II'DRATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY E] RWQCB LEAD- ❑ RWQCBLEAD- <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) El DTSC LEAD ❑FE 2954 LEAD <br /> 2950 2953 29601352613527 2965 2959 2954 <br /> FACILITY FI LE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> 15 THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YESY No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YEs ❑ No ❑ <br /> BUBINEBSIFADILIIYISITFIPROIECTNAME 7-Eleven Store#39208 APN. <br /> 209-440-35 <br /> SRE ADDRESS I PROJECT LOCATION BUSINESS PHONE <br /> 25460 South Schulte Road <br /> CITY Tracy <br /> STATE CA zip 95377-9709 <br /> BOARDOFSUPERVIBORDim= LOCATION CODE KEY1 KEY2 <br /> MAIDNO ADDRESS,IF DIFFERENT FROM FAcan Y ADDRESS <br /> MAiuwBADUNEEBCnY STATE LP <br /> SIC CODE COMMENn <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 Amaqda Magee- Stantec Consulting <br /> ATTENTION:ORCARE OF/OFTO L) <br /> MAIUND ADDRESS PHONE <br /> 555 Capitol Mall Suite 650 <br /> Clry Sacramento STATE CA ZIP 95814 <br /> ACCOUNTAGDRm TOSENUFEESANDCHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLINGIV <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or <br /> Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br /> this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided tome or in represen alivee. <br /> APPl1DANr NAMe(PLEASEPRINT) Amanda Magee, on behalf of 7-Eleven, Inc SIGNATURE / ln—L <br /> TITLE Senior Geologist TAZIDa <br /> FA#: fa 11 ah OWNER ID#: 092002-2-7/5- <br /> ILIPL � {/DUS AOOOUNO: A�M / ASSIGNED TO: <br /> PR#: UV ACCOUNTING COMPLETED BY: DATE: p <br /> 17 <br /> SR TYPE PE SC _NLIff0 AMT REMITTED CHECK# RECV'D BY DATE SERVICEREQUEST INVOICE# <br /> Work Plan 2903 52345 S rAy <br /> 2904 523 $760.00 6O <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />