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San Joaquin County Environmental Health Department <br /> N FORM <br /> DATE 10/26/2 012 MASTER FILE RECORD INFORMATION i6NlFR" SITE MITIGATION ION 8 LOP <br /> =00' UNIT IV <br /> arAtsvogEHDUSlQtaY QwNeRID 4e <br /> GEST f OWNER"im"mrl:ravFtrFwtm EHD Q <br /> OVMER FI LE:COA01=rHEFOLL0AWG PROPERTY OWN INFORNAT1oN: ti <br /> PROPCant HAW Robert O Scott { } N/A <br /> Mr Last PIMMENUMBER <br /> Fust i <br /> E-mAa.Awm ss <br /> SussttsNAhTe <br /> No business at site (empty lot) N A <br /> Owner Hasa Address <br /> 120 23rd Avenue <br /> STATE ZAP <br /> city Santa Cruz CA 95062 <br /> Owrw Mntling Address 120 23rd Avenue <br /> I&WMAM—Cmy Santa Cruz SnA zrP 95062 <br /> CORPORATION❑ INavtoVAL® PARME<M P❑ F®AGENV❑ (YMER© <br /> am IY moATION�CNv/RONMQNAL AssP.Ssmarr,,^VoLut rARY CLMMP_WATER QUALITY_HW PIPMUNS INVEMOATION—LOP <br /> FAauTy100 '-4ACCOUNTIO PR# O Asa EDEYPLoree7EA.Aorwr.EH0_RWQCB_,L_DTSC_EPA— <br /> ���� <br /> ..FACILITY FILE COMPLETETHEFRLCOIWNG BUSINESS I FACILITY/SITE INFORmATrvN.' <br /> s <br /> Is this a WEwBuslness LOCATION not previously regulated by the ENviRommENTAL HeALTH DEPARTMENT? YES ❑ No a <br /> Is this an EXISTING Business LOCATION buts NEW TYPE of regulated Suslrless? Yes ❑ No M <br /> BUtfNEssIFAauTy)SrENAME California Fuels Cardlock station <br /> SnEADDREHs SNIrE0 QWNEssPHONE <br /> 2402 Pacific Avenue <br /> j QA7Y STATE ZfP <br /> 1 Stockton CA 95204 <br /> 80ARDCFSUAMn=RDMTrcoT 7-- LocAnoNCDDe ' Kerr KEY2 <br /> MaMw Ad*wm b VVFERENrfmnrFaa#&yAe s AtLardlatt arCare Of(aptlwW <br /> P.O. Box David Atwater <br /> elallIngAtkimssCty P.O. Box 11.07, Stockton, STATECA 95201 <br /> STO CDDe APNE Commwr: <br /> THmn PARTY BILLING INFO: Q?M fete If Boring Party Is different from Property Owner orFacility O enator identified above. <br /> BUSMEWNME David Atwater Atterteo morCamOf fap e <br /> nletunaAd,ltass P.O. Box 1107 MOM <br /> cary <br /> Stockton CAre 95201 <br /> far fees and Charges OWNER 1`ACILIT ffiusINESs THIRD PARTY BILLING <br /> BR-LINO AND COMPM QjCX AC"0Y 0GMWT: I,the undenIgned Appli-0,certify that i am the 01mer.OporWr,or ArrrhnrftM Agent of this Business,and i aekuowledgo that all PMUUT FEES, <br /> PFWALISF.S„ENFORCEMPTCA4RCIS andlor HODIMT 07ARGES associated with this Operation will be billed tome at the address Identified above as Nse.4coomrrAnnxtrst•for MR site. I also certify that <br /> all Information Provided on ICFs tppscalion is true and correct,and rkat ati regawod adivitles wtit be Performed is aceordaru:e with all applicable SAN JOAQLM COMM Ordfntaet Cadrs and/or <br /> Standards and STATE and/or RmEvAL Laws and Rttulatiorm As the undersined owner,operator,or agent IF the propnty tocated at the Above t7x3tstylsite oddres,I hereby antharise the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN C0194TY FtIMPONM AWAL IIEA[.TN DEPAR'T'MENT ae soon as it is avalfabte and st the same dme it Is <br /> provided to me or my representative. <br /> APPLICANTNAME(PLEAsiePftwo David Atwater steerAruRE <br /> TITLE TAxID# .. <br /> Ap !]etc Acce orlke Pros Co kftd Rv pa18 <br /> arnt llMTrtDATKIFA AtaouNrPAtD DATR OF PAYMrW PAYMENT TYPE Mots"* Q}1CCIS REa®vm By WORK PLAN PE <br /> M$-1 <br /> -. -. ..-- .... ...... .. ...-. .., .- <br /> EC <br /> I <br />