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MEMNON <br /> • SAN RUIN COUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> DATE 10-03-12 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 2co (P SITE MITIGATION &LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDTD •VVO' CARET G 3 7 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHWKIFOMER/s CURREHnYONRLEMM EHO � <br /> PROPERTY OWNER NAME Fassel(Philip) Elder (209) 662-0952 <br /> FRSs MI L45T PHONE NUMBER <br /> BUSINESS NAME LAODREBS <br /> na a <br /> OWNERMWEAMRESS <br /> 837 Shaw Road <br /> Cm <br /> Stockton STATE CA Lp <br /> 95215 <br /> OWNER MAILINGAODREBS Same as above ENVIRONMENTAL HEALTH <br /> MAILINGAOopten CITY ,}5 STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL - ❑PARTNERSHIP ❑GOVERNMENT AGENCY I-y RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP. _ WATER QUALITY HW PIPELINE INVESTIGATION_ LOP <br /> -tFApcMwTY IDT INv'il,.y O,A,,c�eouNT ILD( PR RO A68IONED EMPLOYEE LEAD AGENCY:EHO_RWgCB�OTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITEI PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES d No ❑ <br /> BUSINESS/FACILETISITFIPROIECT NAME Former Rainwater Car Wash <br /> SITE ADDRESS I PROJECT LOCATION 420 W. Yosemite Avenue SUITE# BUSINESS PHONE <br /> Cm Manteca STATEAZIP 95336 <br /> BOARDWSUPERVISORDISTRICT LOCATION CODE KEY1 NEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILnY ADDRESS ATTENTION:ORCARE OF(OFfrORAL) <br /> 837 Shaw Road Philip Elder <br /> MAIUNG ADDRESS Cm STATE ZIP <br /> Stockton CA 95215 <br /> SIC CODE APN# COMMENT: <br /> 21 -31'Z w <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Ami Adini&Associates, Inc. ATTENTION:ORCARE OF (OPTRJHAL) <br /> Larry VJitwer <br /> MAILING ADDRESS PHONE <br /> 4130 Cahuenga Blvd., Suite 113 (818)824-8102 <br /> CITY Toluca Lake STATE CA ZIP 91602 <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPunrvCE ACKNOWLEDGMENT' I,the undersigned Applican4 certify Hut I am the Owner,Operator,Authorized Agent,or Responsible Parry And I aelmowledge that all PE"fl,FEEs, <br /> PENALTIES,ENFORCEMEMCHARCE,S and/or HOURLY CHARGES associated with this project will be billed t0 me at the address identified above As the ACMUM ADDRESS for this site. 1 also certify that an <br /> information provided on this application is true and correct;and that as regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agen4 w RevgroRvible Parry for the project lorated above under faciUty/site address,I <br /> hereby authorin the release of any and all results,reports,and other emiromnenial assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a,soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> A ` <br /> APPLICANT NAME(PLEASE PRINT) LARRY WITWER,Ami Adini&Associates, Inc. SIGNATURE <br /> TITLE! Sr, Project Manager Tax ID III <br /> APPROVEDBY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MI AMOUNT PAID DA OF PAYMENT PAYMENT TYPE RECEIPT# CHECK RECEIVED BY WORK PUN PE <br /> FEE:f '31C j� `� 157 <br /> J Lm *13ZILf 3 <br />