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San J,'juin County Environmental Health L-ml..artment <br /> DATE b5 )23 12-- MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDA CASE#L'/j 015r v M T IV <br /> OWt+IER FILE:CONPLETE THEFOLLOWfNG PROPERTY OWNER/NFORMATfON: CHEcmw OWNER CURREHTLYoHF/LE W/TH EHD O <br /> PROPERTY OWNER NAME Ellis Cecchinin - } <br /> First Ml Last PHONE NUMBER <br /> BUSINESS NAME former Cherokee Truck Stop E-MAIL AD DRESS <br /> Owner Home Address 3000 E.18th Street <br /> city Antioch gCa zip <br /> 94509 <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDNIDUAL W( PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION—LOP XX <br /> FACILITY ID# INVO AccouNT ID PR OI'RO# <br /> Z-2 5j 38'SS� Ro- , <br /> FACILITY FILE COMPLETE THE FOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExisTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 191 <br /> BusINESS/FAOIuTY/SITE NAME former Chrokee Truck Stop <br /> SITE ADDRESS 3535 East Chrokee Road SUITE# BUSINESS PHONE <br /> CITY Stockton STATE CazIP 95205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address HDIFFERENThrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE Zap <br /> SIC CODE APN A 12 COMMENT: <br /> �C�oU-Oce <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME Advanced GeoEnvironmental Attention:orCare Of (optional)William Little <br /> Mailing Address 837 Shaw Road PHONE 209 467 1006 <br /> Crtr Stockton STATE Ca zp 95215 <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANcF AcKNOwLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CtiARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address Identified above as the ACCOUNTADDRESS for this site. 12130 certify that alI <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 facitity/site address,I 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 32me time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) William Little SIGNATURE <br /> TITLE Geologist TAX ID# <br /> Approved By Data Accounting Office Processing Completed By L,6Data <br /> SITE MITH3;j AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT I) CHECK# RECEIVEO BY '..WORk P1:J .�- <br /> FEE:$ - S'Z <br />