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San Join County Environmental Health Deoment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 11 11/23/2010 SITE MITIGATION &LOP <br /> SHADED AREASFOR EHOUSE ONLY OWNER IO# CASE# UNIT IV <br /> OWNERFILE:COMPLETETNEFOLLOw No PROPERTYOWNER/NFORMAT/ON.' CNEcKbe OWNER CURRENTLYONFILEW/TH EHOE:1 <br /> PROPERTY OWNER NAME NA NA ( ) <br /> F1sf MI Last PHONE NUMBER <br /> BUSINESS NAME EMAILAomESS <br /> TOC Holdings markchandler@tocholdings.com <br /> Owner Home Addreae <br /> 2737 West Commodore Way <br /> city <br /> Seattle STATEWA <br /> zip 98199-1233 <br /> Owner Mailing Address <br /> Melling Addreas City State yP <br /> CORPORATION® INDIVIDUAL EI PARTNERSHIP[-I FED AGENCY El OTHER[I <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY 10 INV# Accouxr l0 PR#I RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB_DTSC_EPA <br /> _ <br /> FACILITYFILE COMPLETE THEFOLLOwfNG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No In <br /> BUSINEBsIFACILITYISITENAME Former Time Oil Terminal <br /> SITEADDRESS SURE# BuwNEee PNONE <br /> 3015 Navy Drive <br /> Cm. STATE ZIP <br /> Stockton CA 95206 <br /> BOARDOFSUPERVISORDISTRICILOCATION CODE KEY1 KEY2 <br /> Meiling Address/f DIFFEREWWOMFaG/#yAddraea Attention:Groats Of(apt/one/) <br /> Mailing Address City STATE LP <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identiBedabove. <br /> BUSINESS NAME Attention:Droste Of( #oral) <br /> Stantec ConsultingCorporation Todd Brown <br /> Melling Address PHONE <br /> 3017 Kilgore Road Ste 100 916-861-0400 <br /> Cm Rancho Cordova STATE CA 7P 95670-6150 <br /> AccouwAOORlr84 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKN gWLEDGMENT: 1,the undersigned Appxeant,claity that I am the thmer,Operator,or Aurhnrized Aeem of flus Dusmees,and I actmowledae that as PSRM/TFA., <br /> PENALnE,ENFORCEMENT CHMGAS and/or HOURL Y C1IANri£.S aamelmed wish this operation wiD be bitted to me at the address Identified above as the ArYXIUNTADDRESS for thb 91h. I she eernry that <br /> all information provided an this epphcafion u true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards end STATE and/or FEDIER L Laws and Regulations. As the undersigned owner,operator,or agent of Use property located at the above facttity/siM address,I hereby au�fLh`oj a of <br /> any and.11results and mdvonmenml assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it u ivaii a�p^ fR u <br /> provided to no,or my represesstative. V lJ <br /> APPLICANT NAME(PLEASE PRINT) �Dd pf ie <br /> PO W A SIGNATURE ,_ R n _' t <br /> TITLE SeA�ef`' �eGo915t TAXID# 33a3,��o89 oouSTY <br /> a�IS � <br /> Approved By Oats Acccuntlnq Office Proceeaing Completed By Data <br /> STH DE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORKPLANPE <br /> FEE: <br />