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San Joaquin County Environmental Health Department <br /> I DATE Iq�l2— <br /> MASTER RLE RECORD INFORMATION`'MFR" GREEN FORM <br /> 3� <br /> SITE MITIGATION& LDP <br /> 9HAoeoaamslm EHDu o OwNEa ID# T0607700064 CUE# 1669 UNIT IV <br /> f <br /> OWNERFILE:COMPLETETNEFOLLOWNGPROPERTY OWNER INFORmwmm CafED OWNERopeaEwnroNPAewraEmo <br /> j PROPFFnOwNERNArIE (253)896-8801 <br /> tam PtioNENUM se <br /> BUNNESSNARE EMAILADbRE9% ''. <br /> Tesoro Refining and Marketing Company Anastasia.E.Duarte@TSOcorp.com <br /> Owrar Ham Address <br /> rrI city BTATE ZIP <br /> ( Owner MallingAddress <br /> i 3450 South 344th Way,Suite 201 <br /> 'Mai#ng Address City Slide ZIP <br /> 98001-5931 <br /> iGDgPD11ATlOxI_1 INDIYmI1AL❑ PARTNEAeHIP[I FEDAOENCY❑ OTxER[], <br /> SITE MITIGATION X ENVIRONMENTALABBEBSMENT VowwmY CLCANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP'_ <br /> FADILIWID# INv# ACCOUNTID PRIIIRO# .ASSIGNED EMPLOYEii LEAD AGENCY,EHD_RWQC8_OTSC_EPA <br /> FACILITYFILE COMPLETErffEFOLLowINGBUSINESS]FACILITY/SITE/NFORMAnov: <br /> Is this a NEW Business LOCATION not Previously regulated by the ENARONMENTAL.HEALTH DEPARTMENT? YEs ❑ No ❑z <br /> Is this an ERISTINe Business LOCATION but a NEWTYPE ofregulated Business? Yes ❑ No El <br /> Bua,Ne.WFAciL /SI NAM <br /> USA 110 <br /> Sne AoUress SUITE# BUsaaaa;PHONE <br /> 2132 E.Mariposa Road <br /> cm, STATE -ZIP <br /> I Stockton CA 95206 <br /> j <br /> BDAIIDGFSUPFAVIBORTNBTPoCr Lotaavi NCODE HEYt KEY2777 <br /> MallIto g Add...Ifp/FFERENrrrom Poaa yAddress Attention:orOare Of(opftoaV <br /> Tesoro Refining and Marketing Company Anne E. Duarte-Wilkinson <br /> ! Mal#ng Address City STATE ZIP <br /> 3450 South 344th Way,Suite 201,Auburn WA 98001-5931 <br /> SIC GORE qPN# CONMENr, <br /> i 173-06-35 SE Corner Farmington Rd/E Mariposa Rd <br /> iTHIRD PARTY BILLme INPo: Complete if Billing Party is different from Property Owner orFacility Operator identffied above. <br /> ' BU%mE9%NAVE Attention:orCan,OF(op#nna// <br /> Environ Strategy Consultants, Inc. Chris Guesnon <br /> Mailing Address PHONE <br /> 1036 W Taft Avenue,Suite 200 (714)919-6526 <br /> icm, STAIE ZIP <br /> Orange CA 92865 <br /> Acaazmu:A ➢iSB farfeas and charges OWNER FACILnyBusMESs THIRD PARTY BILLING <br /> ' HR;WIiG ANOCOaPLIkYCE 4CEP.OWLEDGMEM1T: I,IM UndL•rSleprll AppgeapQLrrllfy fhn[]nm the 0rvneq xpefNn6 UrA1/lhPdrfd Agenr UrehN BaSinCSS,aMll a[ImUlVledpe(ABI ag PPRdfflFPGS, <br /> )•PNILTMS,H XOA HEATCRIPR AnNor ROUMFCNnaaa Iwodatedeffh This operadon will be bi#ed to nxatthe addressidrntified abovras the At, rATrlaaaEtS for this site, f ah.unify that <br /> all iprm'm2xan provided on this application Is true and correct and tls:N all Maid sed activities will lis port toed iv vcr.Nmlcewitp Ail applicable Sul JoAQUP Co,x Onlono.Codes AW., <br /> Snarl. b and STATE and/or I MEMAt Laws and Regulations..As the Undersigned am net,operator,or stent ornrepropertylocaNd atlhe above fa UTit.YMIO nddren,l hereby enha ft d,rdeaseor <br /> any and all mailh and nMrnnmenrat a Oaeent information to SAN 1OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and.r the mmr Nme It h <br /> provided to ma.T On,mpresaatativv <br /> APPLICANTNAME IPLEAGE Paw) 1��hG N,Tlrit:a1rt SIGNATURE <br /> TITLE TAXID1F ' <br /> �. # ia . m 33-- 0765643 <br /> A pro ad B Deb pcwunsna Ofice Procoemng Compleletl ey pat <br /> SITE MRsalnox AMOGNr PAID D¢TE O➢PAYMENT PAYMOiT TYPE RECEIPT# <br /> GHEGN# RCCaVEDBY YJbp_N P{Ar11'E <br /> FEE'.f <br />