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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE I October 13, 2016 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: 0AZGx1FOwxeR15canaenrcroxFa1w EHD❑ <br /> PROPERTY Phillips 66 Company PHONE <br /> OWNER NAMEIRE. :, 1(510)245-4423 <br /> ILA <br /> BUSINESS NAME Phillips 66 Company E-MAORSES <br /> sharon.De.evans(ZDp66.com <br /> OWNER HOME ADDRESS 1380 San Pablo Avenue ATTENITON:ORCARE OF(OFROML) <br /> cnv Rodeo STATE CA LP 94572 <br /> OWNER MAILING ADDRE88 same as above <br /> IMIUNO ADDREBBCM STATE LP <br /> i <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY ❑RESPONSIBLEPARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARYJ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ pTSC LEAD EFED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTON WATER QUALITY(VR) <br /> 2858 2954 <br /> 2950 2953 29601352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BVTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BuSINESSIFACILITY/SaSIPRo eoTNAME Former Circle K Store#06671 APN' 072-420-19 <br /> SITEADDREB9IPROJEOTLO0ATTON 8606 Thornton Road BUSINESS PHONE(209)478-8959 <br /> c1D' Stockton STATE CAZ"95209 <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MARINO ADDRESS CITY STATE ZIP <br /> SIC CODE COXMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTYOWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATC Group Services LLC ATTENTION:GROANS OF(OPFWRAo <br /> MAIUNO ADDRESS 1117 Lone Palm Ave., Suite 201B PHONE(209)579-2221 <br /> cT" Modesto STATE CA ZJP 95351 <br /> ACCOUNTADORESB TO BEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACI(NONLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site.I also certify that all information <br /> provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site Rddress, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPUMNTNAMEIPLEMEPRINT) Jeanne HOmsey SIGNATUR N <br /> TITLE Branch Manager-ATC Group Services LLC TAXID# 460399408 <br /> FAA. FQ00;Z.37i+ AOCOUNTE: /I���l�� ABSNINEDTO: <br /> PRS' ACCOUNTING COMPLETED BY: /-f 3 DAT= / <br /> 932015 <br /> Site Mitigation MFR 29- <br />