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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> DATE 10-03-12 MASTER FILE RECORD INFORMATION_`EMFR" GREEN FORM <br /> Q�XO?' SITE MITIGATION& LOP <br /> IMAGED ARCO R HO SE ONLY OWNER IDT OWOO� CABER UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATIuFA. CHECKJF OW ERfa CURRENTLravrAE WrH END <br /> PROPERTY'OWNERNAME Fassel (Philip) Elder �209) 662-0952 <br /> FIRST Ml LAST PHONE NUMBER <br /> BUBINEw NAME n IL ADORESB <br /> a <br /> OWNER HOME ADDRESS <br /> 837 Shaw Road <br /> Cm _ <br /> Stockton STATE CA ZIP <br /> 95215 <br /> OWNER MAIupG ADDRESS Same as above ENVIRONMENTAL HEALTH <br /> MAILING ADDRESS Cm <br /> STATE 7JP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCYr�5 <br /> C]RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP_ <br /> FACILITY ID# INV# ACCOUNTIO PREY ABMGNED EMPLOYEE LEAD AGENCY:EHO_RWQCBg_OTSC_EPA_: <br /> qAw Z\ _ f�RW DLII / JolfuuY <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> ISTHISA NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No FLI <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES LX] No ❑ <br /> BUSINEBNFACILITY/SITEJPROJECTNAME Former Rainwater Car Wash <br /> SITEADDREW/PROJECTLOCATION <br /> 420 W. Yosemite Avenue SUITE BUSINESS PHONE <br /> Om Manteca STATEA 95336 <br /> BOANoWSUPERVMORDISTater LOCATIONCODE KEY1 K12 <br /> MAIUNG ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(G TIOMAL) <br /> 837 Shaw Road Philip Elder <br /> MAIUNGADOREBBCm STATE LP <br /> Stockton CA 95215 <br /> 11 SIC CODE APN0 COMMENT: <br /> 11 ZI -312 (P 11 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Ami Adlnl&Associates, Inc. ATTENTION:ORCARE OFO/TgNAL <br /> ( ) Larry Witwer <br /> IEAILINO ADGRESB PHONE <br /> 4130 Cahuenga Blvd., Suite 113 (818)824-8102 <br /> CITY <br /> Toluca Lake STATE CA LP 91602 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant.certify that I am HM Owner,Operator,Authwiud Agent or Rmpnnsible Party end I acknowledge that all PEWITFEES, <br /> PENALTIES,ENFORC£M£NI'CHARG£S SadlerrJOURLY CHARGES associated with HRS project WIII be billed t0 me at the address identified above as me ACCOUNTADDRESS for this Bite. 1.6.cRDfy dust all <br /> information provided on this application is 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 and STATE eM/or FEDERAL Laws and REGLLATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under faNity/site address,I <br /> hereby authorize the mime of any and all results,report,and other environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONWWAL HEALTH DEPARTMENT SA soon as it Is available <br /> and at the same time it is provided to me or my representative. AIMR ` <br /> APPLICANT NAME(PLEASEP1Usm LARRY WITWER,Ami Adini&Associates, Inc. SIGNATURE IJ}•"'�'+ <br /> TITLE Sr, Project Manager TAXID# �T <br /> APFRGY¢D BY DATE ACCOUHRNO OFNOE PROGESSINO COMPLETED BY GATE Z /� <br /> SITE 1Sn)6AV M AMOUNT PAID DATf OF PAYMENT PAYMENT TYPE RECEIPT# <br /> FEE: CHECK# RECEIVED BY WORK PLANPE. <br /> -Zg57 <br />