SITE INFORMATION AND CORRESPONDENCE FILE 1

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SAN J,,.lUIN COUNTY ENVIRONMENTAL HEALTH ,,.,�ARTMENT DATE 05/29/14 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASES 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 ADDRESS CITY Dallas STATE TX zIP 75221-0711 El CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY IF]RESPONSIBLE PARTY ❑OTHER SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNT ID PR#!RO# GENCY:' HD_:-,I€2WQCB,"DTCA�. 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/SRE/PROJECTNAME 7-Eleven Store#14117 SITE ADDRESS/PROJECT LOCATION 2725 Country Club Boulevard SUITE# BUSINESS PHONE CITY Stockton STATE CA ZIP 95204 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY STATE ZIP SIC CODE APN# COMMENT: Lo 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(oPnoNaL) MAILING ADDRESS PHONE 3017 Kilgore Road, Suite 100 916-861-0400 Cm 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 Owner,Operator,Authorized Agent,or Responsible Parry,and I acknowledge that all PERMIT FEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will he billed tome at the address identified above as the A CCOUNTADDRES.ti 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 Onwer,Operator,Authorized Agent,or Responsible Parr for the project located above under facility/site address,1 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(PLEASEPRINT) Debbie Lichtenberger $IGNATIJRE / G1� /L� TITLE Environmental Tech/Permit Coord., Stantec Consulting Services Inc. T-IDS APPROVED By DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY -W O'LAN4 FEE:$