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San Joaquin County Environmental Health Department <br /> DATE 11 05 2__ MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> / —L SITE RMIITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# V S(� r M ■ IV <br /> d=RFILE:COUPLETETHEFOLLOW/NG PROPERTY OWNER/NFORIHAT/ONCHECK/F OWNER CURRENTLYOHF/LEW/THEND E] <br /> PROPERTY OWNER NAME Ellis Cecchinin <br /> First I MI Last PHONE NUMBER <br /> BUSINESS NAME former Cherokee Truck Stop E-MAIL ADDRESS <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_ENVIRommENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP XX <br /> FACILITY ID# INV# Accou.NT ID PI2#l+RO# 8 ',� P � � �� >� * -fit t� <br /> x ` <br /> P+Ys 3Y 11 a t r <br /> c fy.rAi,y <br /> Ro- J rtes . PzX <br /> FAC1LJT7F1La COQ/PLETETHEFOLLOWING BUSINESSI FACILITYI SITE/NFORmA77om <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No KI <br /> Is this an ExIS'nNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BusINESs/FACIUTY/SITE NAME former Chrokee Truck Stop <br /> SITE ADDRESS 3535 East Chrokee Road SUITE# BUSINESS PHOW <br /> CITY Stockton STATE Caz'P 95205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION,CODE KEY1 KEY2 <br /> Mailing Address WDIFFERENThvm Fae ityAddress Attention:orCare Of(optionaf) <br /> Mailing Address City STATE zip <br /> IF <br /> SIC CODE IAPN# 1 COMME00 <br /> NT: <br /> THIRD PARTY DILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Advanced GeoEnviron mental Attention:orCare Of (optfonai)William Little <br /> Mailing Address 837 Shaw Road PHONE 209 467 1006 <br /> CITY Stockton STATE Ca ZIP 95215 <br /> AccouwrADDREss for fees and charges OWNER FACILITY/BUSINESS THIRDpARTY BILLING <br /> BILLING AND COMPLIANc6 ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that 211 PERHIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address Identified above as the ACCOuNTAnnxess for this site.I also certify that all <br /> information provided on this application is true and correct,and that ad 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,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 same time it is <br /> provided to me or my representative. ry % <br /> APPLICANT NAME(PLEASE PRINT) <br /> William Little SIGNATURE W <br /> TITLE Geologist TAX ID# <br /> Approved By Data Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY �,WORk <br /> FEE:$ .Sz <br />