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vAN,1 UIN COUNTY ENVIRONMENTAL <br /> SITE MITI ION MASTER FILE HINF' <br /> RECO PARTMENT <br /> DATE March 6, RM INF ATION FORM <br /> 2017 "MFR"- FORM <br /> OWNER FILE:COMPLETE PROPERTY OyyNER/RESPONSIBLE PA <br /> PROPERTY SHADED <br /> OWNER N Phllli s 66 C RTY INFORMATION: AREAS FOR EHD USE <br /> AME Corn an CHECK/FO <br /> BUSINESS NAME IRS SER/SCURRE <br /> Phillips 66 Co M RrtravFTtExnnY ENDEJ <br /> y� IAS? PHONE <br /> OWNER HO mpany <br /> ME ADDRESS <br /> CITY E-MAILADORE88 <br /> Rodeo ATTENTION:OR CARE OF(OPTOq.44I sharon.e.e <br /> OWNER MAILING ADDRESS vans <br /> 66.com <br /> MAILING ADDRESS CITY same as above STATE <br /> CA ZIP 94572 <br /> ®CORPORATION E]INDIVIDUAL <br /> LP <br /> INDIVIDUAL ❑PARTNERSHIP <br /> ❑ ENVIRONMENTAL ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY <br /> ASSESSMENT El EHD LOCAL VOLUNTARY <br /> CLEANUP ® RWQCS LEAD_ ❑OTHER <br /> 2950 2853 CORRECTIVE ACTION AT RWQCB LEAD_ <br /> 2960/3526/3527 WATER QUALITY(WpR El DISC LEAD FED EPA LEAD <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: 2965 ) 2559 2954 <br /> IS THIS A NEW PR PR LOCATION <br /> IS THIS AN ELDSi1NG PREVIOUSLY REGULATED BY THE ENVIgpNMENTAL HEALTH DEPARTMENT? <br /> PRWEC7 LOCATION,BUT A NEW SCOPE OF WORK? <br /> YES ❑ Na <br /> BUSINESSIFALInY/$GE/pROJECT NAM <br /> 76 Station YES ® NO ❑ <br /> SITE ADDRESS/PNp1EGT LOCATION APN: <br /> 1206 March Lane <br /> CTry BUSINESS PHONE <br /> Stockton <br /> BOARD OF SUPERVOOR DRI7NICT LDrwTION CODE STATE C++ALP 95210 <br /> KEY1 <br /> MAILING ADORES,IF DIFFERENT FROM FACILITY ADDRESS KEY2 <br /> MAILING ADDRESS CITY <br /> STATE zip <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATC GroupServices LLC- Consultant <br /> ATTENTION:ORCARE OF(DPl701NALf <br /> AWuND ADoRE88 <br /> 1117 Lone Palm Avenue, Suite 201B PHONE <br /> COY Modesto <br /> STATE CA ZP 95351 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ <br /> FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> TILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator,Authorized Agent, <br /> r Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES an <br /> HOURLY CHARGES associated <br /> pith this project will is billed to me at the address identified above as the AccoUNTAnnRESS for this site.I also certify that all information <br /> rovided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> DAQUIN COUNTY ORDINANCE CODES and/Or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> caner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> lease of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br /> EALTH DEPARTMENT as soon as it is available and at the same time it is provided to me Or my representative. <br /> ENVIRONMENTAL <br /> PPUCANTNAME(PLEASE PRINT)Jeanne Hornsey <br /> SIGNATURE <br />"'LE Branch Manager/ATC Group Services - Consultant <br /> rAxlDa 4609408 <br />.a: <br /> OWNER ID/I:DWZ;L�6 56 <br /> r ttW tltl' ACCOUNTM; A8810NED TES: <br /> ACCOUNTING COMPLETED BY: <br /> IOW -L/1J DATE: <br /> I-2015 <br /> e Mitigation MFR 29- <br />