Laserfiche WebLink
GREEN FORM <br /> DATE 04/19/2011$K MASTER FILE RECORD INFORMATION "MFR" <br /> HNAO ^AREAgFOREHDOHEOMLY OWNER lot CAeEs UNIT IV <br /> �t�00 g <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NG PROPERTY OWNER INFORMAT/ON: <br /> CUECK/r= OWNER Cuaae:NTL rraYrice wnTf EHD <br /> PNONE 925-7542058 <br /> PROPEmYOwra=R NATE <br /> First MI Last <br /> Buarsas NAME: CHEROKEE TRUCK STOP(FORMER) SocSm/TAx IDR <br /> owner Home Addres '300078th STREET DRIVER'S LICENSER <br /> City AnSoch STATE CA ZIP :tet <br /> Owner Mailing Add... NA <br /> Sfafe NA Zip NA <br /> ^ Me10n8 Address Gty NA <br /> O <br /> cORHroRATaN❑ IlalmaHAL❑ PARTIERHHP❑ Fm AGENCY❑ OtdES❑ <br /> 1 <br /> FACILITY FILE <br /> 06P� Accouter 10R IrwR <br /> COMPLETE THE FOLLOW/NG BUSINESS/FACILITY t SITE INFORMATION: <br /> Is this a New Business LOCATION not previously regulated by the EWRONMEfTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is We an OusnNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> ausimEssivacgmis—w— CHEROKEE TRUCK STOP (FORMER) <br /> snEAmREHH EA TCHEROKEEROAD SUITES BUmrE88 Rtort <br /> STATE CA ZIP 95205 <br /> C YSTOCKTON <br /> �`Jr BOARD OF BGPfnvMOR DIama:T LOCATION CODE KEY7 KEY2 <br /> 1)C Meiling Address fOFFEREN/Rom FicMiyAddn Atanton:ar Care Of(opHiaml) <br /> 0. STATE ZIP <br /> McMrhg AddressCKy <br /> qgICBQgE APNR COMMENT: <br /> N< TNIRD PARTY BILLING INFO: Complete N Billing Party Is different from Property Owner orFacllity Operator identfied above. <br /> ltl. Buelesse NA1E ADVANCED GEO ENVIRONYEMAL,INC Atentlon:urCare Of (opdwTs?)ALLISON COLAVRA <br /> !� PHota=2094671006 <br /> ^ <br /> Melling Address 837 SHAW ROAD <br /> ` Cm STOCKTON STATE CA ZIP95216 <br /> ACCOf/NT A90BEW for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> a B G AND COMPtJANe6 ACgVOTYLRDGMBNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent oflhis Business,and l acknowledge that all PHRMTr Fens, <br /> f'mYA[TnLr,1:'wwRCm�urCm utans and/or HOt1RLTCAARrauY associated with this operation will be billed to me at to address Identified above a the AmOomrADDRESS for this Site l also certify <br /> that at Information provided on this application is We and correct and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes <br /> e� a^dfor Standards and STATE and/or FRDHRAL Laws and Regulatiom As the undersigned owner,operator,or agent of the property located at the above facility/Ate address,I hereby authorize the <br /> release of y and all results end environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL DEALT[DEPARTMENT as soon as it is available and at the same <br /> an <br /> time it is provided to me or my r(ere.senAtativ/e�. PLEASE SIGNATURE �APPLICANT NAM /L/ LL1 <br /> TITLE7 C<- DRIVER'S LICENSER �\a, <br /> '7 '7 Lsr YRFQuIRFV <br /> a <br /> � 29 So <br />