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San Join County Environmental Health Dell-Oment <br /> DATE11 02/02/2011 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHAOEO AREAS FOR END usE ONLY OWNER to# CASE# \oO 1U 10 \ UNIT IV <br /> OWNER FILE <br /> CoMPLeTErHEFoLLomNGPROPERTY OWNER/NFoRSAnom ONECarF OWNER CURANsv7.Y0NlZLENa x EHO <br /> PROPERTY GWNFA NAME JERRY CASTRO PHONE 209-478-5504 <br /> FHst M1N Last <br /> BUSINESS NAME PACIFIC CAR WASH SOCSECITAKIO# <br /> Owner Home Addreas, 4405 Pacific Ave DRIVER'S LICENSE# <br /> City Stockton STATE CA Lp 95207 <br /> Owner Maitre Addr— 4405 Pacific Ave., <br /> Mailing Address City Stockton state CA TLP 95207 <br /> CONPoMTNNI® INOMWAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER L1 <br /> FACILITY FILE <br /> FACILITY to# CROSS REF IO# (� r, pl /tccp NTID# 35 INV# <br /> COMPLETE rHEFOLLowtNG BUSINESS/FACILITY I SITE tN`FORMfA[T/oN.' <br /> Is this a NEW Business LOCA noN not previously regulated by the ENVIRONMENTAL HEALTH NO 0 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? Y <br /> EIu3INEss1FACILDY/SOENAME PACIFIC CAR WASH AL I <br /> IF gmi <br /> SITE AUORESS 4405 Pacific Ave sulk It BlwWme PHONE p9,a�_5Ma <br /> CITT Stockton STATE zip 95215 <br /> BOARO OF SUPERVISOR DISTRICT LOCATION CODE REY11 NEY'L <br /> Mailing Addreas ifDIFFEREArr from Facility Address Attention:or Cam Of(optional) <br /> Mailing Address,City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator Identified above, <br /> BUSINESS NAME Advanced GeoEnvironmental, Inc. Attention:orCam Of (optional) <br /> Mailing Address 837 Shaw Road PHONE 209-467-1006 <br /> Gi- Stockton STATE CA Lp 95215 <br /> AccCunrAgagEtis for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACENOW LEDCMENT: 1,the undersigned Applicant,certify that lam the Owno,Operator,or Amholkad Agent of this Business,and I acknowledge That all PIERsOrY'EEy, <br /> PENILiTFS,ENFORCEMENT QLIRGES arnd/or flonaLYCN4RGFs assocuted with this operaaon will be billed to me at the address identifiedabove as the ACCTIONTAOpatSs for this site lot.certify that all <br /> information provided on this application is time and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQM CoO Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws Arad RegWafiam. As the undersigned owner,operator,or agent of the property located at the above facility/site address,l hereby Autherhe the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT As soon as it N available and at the same time it is <br /> provided to me or my representative <br /> APPLICANT NAME TIMOR tHY CVt 1I 4 PLEASE PRINT SIGNATURE 7NV1 \� <br /> TITLE PROJECT MANAGER DRIVER'S LICENSE# TAX ID 68-0354606 <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date 7777711 AccmntingOfFice Prmossing Completed By ` Dab <br /> 29-002 Apri125,200] <br />