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San Joaquin County Environmental Health Department <br /> DATE 04/19/2011 k1 "MFR" <br /> GREEN FORM <br /> MASTER FILE RECORD INFORMATION MFR <br /> SHADEDAREAS FOR EHD USEONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOWING PROPERTY OWNER INFORMATION: DIECKIf OWNER CURRENTLYONnLEW/m EHO <br /> PRoPEErr OWNER NAME PNIoNE 925754-2056 <br /> First MI Last <br /> BuslNEss NAME: CHEROKEE TRUCK STOP(FORMER) SOCSECITAx ID# <br /> Owner Home Address 300018th STREET DRNER's LICENSE# <br /> City Antioch STATE CA Zip 94509 <br /> OwMr Mailing Address NA <br /> Melling Address City NA State NA Zip NA <br /> CDNpogatim INDIVIDUAL❑ PARTNERSHIP❑ Fm AOENcY❑ OPER❑ <br /> FACILITY FILE <br /> O�f�r/ ACCOUNT ID# INV# <br /> COMPLETE THE FOLLOWING BUS INESS/FAC I LITY/S ITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No ❑ <br /> Is this an EASONG Business LOCATION but a NEW TYPE of regulated Business? yes ❑ No ❑ <br /> BusimessIFACILIIY/SfTENAME CHEROKEE TRUCK STOP (FORMER) <br /> STIE ADDRESS 3535 EAST CHEROKEE ROAD SUrE# BuslNEss PtaRE <br /> CITY STOCKTON - STATE CA Zip 95205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI KEY2 <br /> Mailing Address ifDIFFEREAfTimm FacififyAddres, Attention:or Care Of/optional) <br /> saw <br /> Mailing Address City STATE ZIP <br /> SIC COOS APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BuslNEss NAME ADVANCED GEO ENVIRONMENTAL,INC Attention:o,-Cam OF /optionall ALLISON COLAVITA <br /> Mailing AddlTass 837 SHAW ROAD PHONE 2094571006 <br /> CnY STOCKTON STATE CA Zip 95215 <br /> _AccouNrAUOR£ss for fees and charges OWNER FAt:ILITY/BUSINESS THIRD PARTY BILIJNG <br /> BILLING AND COMPLIANCN Ac"oyeLaocmaNT: L the undersigned Applicant,certify that I am the Owner,Opemor,or Authorizedtgent of this Business,and I acknowledge that all PERAIITF'Fes, <br /> laN tTa,ENMRcrs7E CH IEC;ES and/or HOU IrCtIASGCS associated with this operation will be billed to me at the address Identilled above as the ACCoorvrAnORYss for this site. I also certify <br /> that all 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 <br /> and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly,located at the above facility/site address,I hereby authorize the <br /> release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY FI NV1RONMENTAL REALTH DEPARTMENT as soon as K is available and at the some <br /> time it is provided to me or my re resentatis . <br /> _ PLEASE PRINT SIGNATURE <br /> APPLICANT NAM ' lC� lr�� 11 <br /> TITLE � <br /> DRIVER'S LICENSE# 10. 41 <br /> / Com_/� v <br /> l7 !X [:S� p D o <br /> 3i �3 � -zs-i� 32 Z /Lt;- z9 so <br />