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�]San Jain County Environmental Health lleartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 5 SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDS CASE# S•Zw(p/ U� O UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON: CHEcKIF OWNER CURRENTLYONFILE WITH EHD <br /> PROPERTY OWNER NAME Ellis Cecchinin <br /> First M1 Last PHONE NUMBER <br /> BUSINESS NAME former Cherokee Truck Stop E-MAILADDRESS <br /> Owner Home Address 3000 E.18th Street <br /> city Antioch SCa zip <br /> 94509 <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL 0( PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP XX <br /> FACILITY ID# INV# AccouNT ID PR#/RO# <br /> 3Mf der �t# °Y�f'§ tS r}r <br /> FACILITY FILE COMPLETE THEFOLLOW/NGBUSINESSIFACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 91 <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESs/FACILITYISITENAME former Chrokee Truck Stop <br /> SITE ADDRESS 3535 East Chrokee Road SUITE# BUSINESS PHONE <br /> cl- Stockton STATE CazIP 95205 <br /> BOARD OF SUPERVISOR DISTRICT '� LOCATION CODE ( KEY1 TEY2 <br /> Mailing Address WDIFFERENT from Facility Address Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> t )_O1O-0 <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Advanced GeoEnviron mental Attention:or Care Of (optional)William Little <br /> Mailing Address 837 Shaw Road PHONE 209 467 1006 <br /> "' Stockton STATE Ca " 95215 <br /> Aca2umrAppmew for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant4 certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed tome at the address Identified above as the ACCOUNTADDRESS for this site. 1 also certify that 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 and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. - <br /> APPLICANTNAME(PLEASEPRINT) William Little SIGNATURE <br /> Vl1Al'} <br /> TITLE Geologist TAxID# <br /> Approved By Date Accounting Office Processing Completed By Data <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE` <br /> FEE:$ <br />