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SanrSTERCFOILE <br /> unty Environmental Health [oartment <br /> "MFW <br /> GREEN FORM <br /> DATE 08-23-2011 RECORD INFORMATION MFR, SITE MITIGATION & LOP <br /> SA EASFOREIID_sN7'y OWNER IDS CASES SRoD�,3S�3 UNIT IV <br /> `` CNSCHfF OWNER CummnywmcE ffm EHD <br /> OWNER FILE:CAtlPLETE INEFOLLOW/NG PROPERTY OWNER/NFORMAnoN: <br /> MAdd� <br /> l <br /> Zumberge � 14� 590-8245 <br /> Firsf MI Last PNONENUMBEfl <br /> Ga LADDRESs <br /> ransportation Inc. <br /> STATE ZIP <br /> city <br /> Owner Mwkv Addreu <br /> 577 W st Phil el his emlee ZIP <br /> Ity <br /> Chino CA 91710 <br /> �I PARTNERSHIP❑ FED AGENCY DINER❑ <br /> CORPORATION t4 INDIVIDUAL❑ <br /> INR Mm"TIGN_L41VIRONMIXTAL AssEmBNENT_VOLUNTARY CLEANUP_WATISR QUALITY_HW PIPEIINE INVP371aNnom_LOP <br /> FACILITY IDi INVi <br /> Accouxr lD ROi ASSIGINEDEMPLOYEE LEAD AGENCY:EHD_RWOCB_DTSC_EPA_ <br /> zSZ i� <br /> 31- <br /> FACILITY FILE COMPLETE 7HEFOLLCWING BUSINESS/FACILITY I SITE fNFORAIINON.' <br /> Is this a NEW Business LOCATION not PraVIOU*1'egW9ted by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEwTmE of regulated Business? <br /> YES ❑ No <br /> BUsiNEssWACiuwiSOENAME Frontier Transportation Inc. <br /> Sunni BUMNESBPNONE 209-836-0251 <br /> SnEAoDREss 425 Larch Road <br /> STATE CA LP 95376 <br /> CITYTracy <br /> BOARD OF SUPERV190fl DISTRICT <br /> LacnnoN CODE KEY1 KEY2 <br /> Mallktg Addreae ND/fFERER7/rwn Fia@1fYAddreee <br /> AEsnyan:t Cam Of(opUorra/1 <br /> STATE zip <br /> Ma ling Addlaee City <br /> SIC CODE APNi COMMENT. <br /> THIRD PARTTr BILLING INFO: Comp/ate if Billing Party is different from Property Owner or Facility Operator identffl above. <br /> Attention:a Cmc Of(OPOM /1 <br /> BUSINE%NAME Ami Adini&Associates, Inc. <br /> PHONE <br /> Mapklg Addlees 616.824.8102 <br /> 4130 Cahuenga Blvd., Ste. 113 <br /> cmLu e .4 t 4K� STATECA Lr 91602—2 r$ <br /> AgpAIRTAgiasw forfaes and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNONLEDGMENT: 1,the naderslgned Applicant,certify that I am the Qwoer,operator,or Anthorned Agent of this RUsims5,and I aelom miedge that ail PERMIT F£Fa <br /> PENALTIM,ENFORCEMENT CHARGES and/or HouR6Y CHARGES associated with this operation will be billed to me at the address idenfified above as the ACCOUNTADURESS for this site. 1 also certify that <br /> wit <br /> licable <br /> odes and/or <br /> all information provided on this application is true and correct;and that all regulated activities will be performed <br /> orthe faccordance <br /> ordanc d ith at[above face SAN oddness,I hereby Ordinance <br /> authorize release of <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned ownI operator, agentproperty <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soo n US it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PIEASEPRIN't) LARRY WITWER,Ami Adini&Associates, Inc. SN3NATUaE V <br /> TITLE Sr. Project Manager(Authorized Agent for Owner) TAX ID# 95-4232841 (AA&A) <br /> Dao° <br /> NTMmd g Deb <br /> APoountln Olflee Praceaellq ComPbbd 8 7� I <br /> SREMITIGATION AMOUNTPAID DATEOFPAYMENT PAYIrENTTYPE RECEIPTS CHECKS RECEIVED BY WORK PuNPE <br /> FEE:$ <br />