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SAN .' `UIN COUNTY ENVIRONMENTAL HEALTIAPARTMENT <br /> SITE MITI%-,,ATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE �°j SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION; CHECK IFOWNERISCURRENTLYONFILEW/7H EHD <br /> PROPERTY lee-.. PHONE 714-731-1050 <br /> OWNER NAME t-IRST M1 AST <br /> BUSINESS NAME E-MAIL D <br /> E uilon Enterprises LLC dba Shell Oil Products US anADc�reE33a.win shell.com <br /> OWNER HOME ADDRE88 ATTENTION:ORCARE OF(OPTIONAL) Andrea Wing <br /> CRY STATE zip <br /> OWNER MAILING ADDRESS 20945 South Wilmington Avenue <br /> MAILINGADDRESSCRY Carson STATE CA ZIP 90810 <br /> 91 CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ® RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD [:1FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <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 /> BUSINESS/FACILITY/SRE/PROJECTNAME Form r Shell Service Station APN 167-150-310-000 <br /> SREADDRESS/PROJECT LOCATIONBUSINEssPHONE <br /> 434 East Martin Luther King Jr Blvd. <br /> CRY Stockton STATE CAz'P 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEv2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE LP <br /> SIC CODE COMMENT: <br /> REQUESTOR'S INFORMATION: <br /> BUSINESS NAME Wayne Perry, Inc. ATTENTION Miriam Urena <br /> MAILINGADDRESS 8281 Commonwealth Avenue PHONE 714-826-0352 <br /> CRY Buena Park STATE CA 7JP 90621 EMML murena@wpinc.com <br /> ACCOUNT ADDRE88 TO SEND FEE8 AND CHARGES: OWNER[] FACILITY/BUSINESS❑ REQUESTOR,I <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, <br /> or Responsible Parry and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CIIARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS 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 <br /> applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br /> undersigned Owner, Operator,Authorized Agen4 or Responsible Party for the project located above under facility/site address, I hereby <br /> authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my re resent five. <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE �j ` <br /> LE TAX ID# <br /> TITLEI? <br /> FA#: ER ID A: UT# <br /> VVO / ti�ED_� GNO <br /> PR#: ACCOUNTING COMPLETED BY: DATE: <br /> NED TO: <br /> ESRE" PE SC FE AMT REMITT D CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> 2903 523 (_J1§6.gV <br /> 2904 523 $760.00 5t7 C1119b a O <br /> Site Mitigation MFR 2-26-2018 <br />