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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> Vb / SITE MITIGATION&LOP <br /> SHADED ENO USEOxY OWNER IDS CASEAt SRcoI"' YI UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: cHEcarteaWNERa cuRRFWTLYONRLE WITH EHDEl <br /> PROPERTYOWNERNAME Rick Rittenberg (925)790-6692 <br /> FIRST MI LAST PHONENLMISER <br /> BUSINESS NAME EAMILADDREBS <br /> Chevron/Phillips 66 rritte@chevron.com <br /> OWNER HOME ADDRESS 6101 Bollinger Canyon Road, Room 3658 <br /> Cm San Ramon STATE CA LP 94583 <br /> OWNER Ma1LIND ADDRESS <br /> MARJND ADDRESS Cm STATE ZJP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION—ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP X WATER QUALITY—HW PIPELINE INVESTIGATION_LOP <br /> FACILITYID# INVt AccouxT lD P RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWOCB DTSC_EPA_ <br /> 1q1 SI `f 31 9HNwN <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATIONOTOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUTANEWSCOPEOFWORK? YES ® No ❑ <br /> BUsimess/FACILmISITEIPRWECT NAME Tidewater Stockton <br /> SITEADDRESSIPROJECTLOCATION 666 West Weber Street SUITE BUSINESS PHONE <br /> Cm Stockton STATE CA ZIP 95203 <br /> BOAROOFSUPERvRCRDIBTRICT / LocATIONCcy / KEVT KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCAREOF/OPOOMAL/ Dan Schreiner <br /> 3017 Kilgore Road,Suite 100 <br /> MAILING ADDRESS Cm STATE CA 7JP 95670 <br /> Rancho Cordova <br /> SICCOOE APN0 70_ OSI COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Stantec Consulting Services Inc. ATTENTION:ORCARE OF/OPTIOWILJ Dan Schreiner <br /> MAILING ADDRESS PHONE 861-0400 <br /> 3017 Kilgore Road, Suite 100 (916) <br /> Cm Rancho Cordova STATE CA 7JP 94670 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERI] FACILITYIBUSINESSO THIRD PARTY BILLING® <br /> BILWNC No Co LUNCD ACKNOWLEDGMENT I,the wdersiVed ApphcanR certify dut 1 am dre Own ,Operator,ANhorkedAgaq or Rerpomibk Pay and I acknowledge Mat a8 P£SMfT ft , <br /> pENA =,ENPORCE,novr CRARCEt and/or HOURLr CHARGES associated w+M Hris projcor wiB be billed to me et rhe address identified above u the ACCODM'ADDR£SS for tl,u siN. I eko certify that all <br /> infG.dw provided on this vppikadon is true and correct;and that all regulated activities will be performed in accordance with W applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.As the undersigned thmer,OperaWr,AathoriudAgart,or Rapewibk Part'for the project located above order facility/site address,I <br /> hereby Authorize the,release of any and all resWts,reports,and other env'vNwenMl a+senneent ivformatiun to SAN JOAQUIN COUNTY E,wmOFPFENrAL HEALTH DEPARrhrFT A,anon on,it is available <br /> and at the same time it it provided to me or my representatim <br /> APPLICANT NAME(PLEASE PRINT)Alejandra HernandezlStantec Consulting Services Inc. SIGNATU-�_ � <br /> TITLE Geologic Project Specialist TAX Ina 11-2 f67170 <br /> ff <br /> OVED BY DATE ACGGUJ NG OFFICE PROCESSING COMPLETED BY DATE MITIOATI N AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORIgLNPE$ <br />