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SIC CODE Commit': <br />REQUESTOR'S INFORMATION: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 10/4/18 SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Howard Sweet PHONE <br />FIRST MI LAST <br />BUSINESS NAME 7-Eleven, Inc. E-MAIL ADDRESS josesios@7-11.com <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (0P770NAL) Attn: Jose Rios <br />CrrY STATE ZAP <br />OWNER MAILING ADDRESS PO Box 711 <br />NAKANO ADDRESS CITY Dallas STATE TX ZIP 75221-0711 <br />CORPORATION <br /> E INDIVIDUAL <br /> E PARTNERSHIP D GOVEUAMENT AGENCY <br /> NI RESPONSIBLE PARTY <br /> <br />OTHER <br />ICI ENVIRONMENTAL III EHD LOCAL VOLUNTARY E RINGICB LEAD— RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (VVDR) <br />2965 <br />M DTSC LEAD . FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />Is THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br /> <br />YES 111 <br />No EX <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br /> <br />YES Ki <br />No <br />BUSINESS/FACILITY/SITE/PROJECT NAME 7-Eleven Store #20632 <br /> APN <br />SITE ADDRESS / PROJECT LOCATION 4627 Da Vinci Drive BUSINESS PHONE <br />crrY Stockton STATE CA ziP 95207 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEy1 KEY2 <br />MAIUNG ADDRESS ,IF DIFFERENT FROM FACIUTY ADDRESS <br />MAIUNG ADDRESS CITY STATE ZIP <br /> <br />BUSINESS NAME Stantec Consulting Services, Inc <br /> <br />ATTENTION Amanda Magee <br /> <br />MAILING ADDRESS 555 Capitol Mall Suite 650 <br /> <br />PHONE 916-669-5982 <br /> <br />CITY Sacramento STATE CA ZIP 95814 Emu_ amanda.magee@stantec.com <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACILITY/BUSINESSO <br /> <br />REQUESTORN <br /> <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES 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 Agent, 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 />ENVERONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pr 'fled to ie o my representative. <br />APPLICANT NAME (PLEASE PRINT) Amanda Magee, on behalf of 7-Eleven, Inc. SIGNATURE <br /> <br />TITLE Senior Geologist <br /> <br />TAx !DO <br /> <br />00 Lizi 7 71 A DOLk.,7t ASSIGNED TO: <br />5 31O DAT-/a 1: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00t <br />$760.00 Lig -:;:C.L. L -X t`; / i 1 or si-00-ri -12)-1 <br />Site Mitigation MFR 2-26-2018