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F <br /> San Jo' ^lin County Environmental Health D jrtment <br /> DATE '1 1 11 9120 1 0 <br /> MASTER FILE RECORD INFORMATION ICMFR GREEN FORM <br /> SITE MITIGATION&LOP <br /> r UNIT IV <br /> SHAVED ARa FOR EHD US ONLY OWNER IDII: CASEA <br /> f• CHECK IF OWNEWCURREAFFLYOIVFREKim EHD❑ r <br /> OWNERFILE,COMPLETETHRFOLtowNG PROPERTY OWNER INFORMAT70N: (925)884-0840 <br /> 1 PROPERTY OWNER NAME G f - - <br /> First M Last PHONENUMBER - <br /> BUSINESS NAME E-MAILADDRESS <br /> Pacific Convenience and Fuel Attn: Duane Blair duaneb Candf.com <br /> Owner Home Address <br /> City STATE- ZIP <br /> PH 08 Ulu <br /> Owner Mailing Address 2603 Camino Ramon, Suite 350 <br /> Mailing address cliy San Ramon $Cq AL HEATH <br /> PER 4 <br /> l- CORPORATION CR INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ - <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> I FACILITY ID II ,�INvfl "�'ACCOUNTID RR�FbRO# ,_ASSItlNEpEMPLOYi:£ LFADAGENCY EHD' �RWQCB. OTSC� `CEPgo_. -;.»ti r"6. °S as »i'$ jp a-a s ,g, x a ,y;, F d� <br /> '� �'p i °�.. t� �l E a"e _ ! -n .._ <br /> FACILITY FILE COMPLETE THE FOLLOWING BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> J is this an Eximwo Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> BUSINEss1FACILITYISITENAME 76 Station No. 11191/5447 - <br /> F $READDRESS - SURE# BUSINESS PHONE <br /> 1469 East Hammer Lane 209 478-1522 <br /> CITY STATE ZIP <br /> Stockton CA 95210 <br /> 'BgAROOF SLIPERVISORDISTRICT ' "LOCATION CODE �� KEY1 ..KEY2 <br /> -; - X, - <br /> Mailing Address K0IFFEREWrfrtam FecXtyAddress Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN fI COMMENT N c _ <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Pro arty Owner orFacility Operator identified above. <br /> Property <br /> BUSINESS NAMED I n Ian Attention:orCare Of topEimal) <br /> Mailing Address PHONE <br /> 11050 White Rock Road, Suite 110 Attn: Dennis Dettloff 916 503-1261 <br /> CITY - STATE ZIP <br /> Rancho Cordova CA 95670 <br /> AccouNTAoaRess for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: ],the undersigned Applicant,certify that 1 am the O weer,Operator,or Anrkorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENAL 77ES,ENF0R(,'EAfEN1'CHARGF-.0 and/or HDURL Y CHARGES associated with this operation will be billed tome at the address identified above as the A CC0IIN7'A1)1)RF.S•S for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will he 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 owner,operator,or agent of the property located at the above farilitylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL-HEALTH DEPAR ' ENT_as soon as it is available andat he-same time it is <br /> provided to me or my representative. - <br /> APPLICANT NAME(PLEASE PRINT) ���{�(� J�/ (! /tom// SIGNATURE r <br /> TITLE r TAX 11]# <br /> Approved By Date Accounting Office Processing Completed By GY' Date 1 <br /> SITE lMITTIIffG'�ATION AMOUNT'PAID DATE OF PAYMENT PAYMENT TYPE R C IPT# CHECK -' . - RECEIVED BY WORK PLA PE <br /> FEE:Y (�� 60 <br /> :: .:a <br />