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San Jo^quin County Environmental Health Il-partment <br /> DATE MAzTER FILE RECORD INFORMATION "Ni RT' GREEN FORM <br /> LOP Ile <br /> i&i , <br /> SITE MITIGATION & LOP <br /> SHwDEDAREA FOREM12USEONlyOWNER ID# CASE* UNIT IV <br /> OWNER FILE:COMPLETE rHEFOLLOW7NG PROPERTY OWNER INFORMATION: CHECKrFOWNER CuaRENTEroNnLEwnNEHDel� <br /> PROPvmOwNERNAME Tony Khatirine ( ) <br /> First M/ Last PHONENumum 209-368-8100 <br /> BUSINESSNAME BAPH31NC. E-M,uLADaxEsa <br /> KHATIRINE@GMAIL.COM <br /> Owner Home Address 14749 N.THORNTON RD. <br /> city LODI STATE CA Zip 95245 <br /> Owner Mailing Address 14749 N.THORNTON RD. <br /> Mailing Address City LODI 8fafe ZIP 95245 <br /> CA <br /> CdiPORATION® INDIVIDUAL❑ PARTNERSHIP❑ FEDAoENOY❑ <br /> OTHER El <br /> SITE MfrIaATION_ENvIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_LOP X <br /> faauTV ID# INv# ACCOUNTID PR#1 RD 111' ASSIGNED EMPLOYEE LEADAGENcY;EHDt RWQCB_DTSC_EPA_ <br /> Ra-SS'o Gf9BE <br /> FACILITYFILE COMPLETE THEFOLLOWTNG BUSINESS/FACILITY/SITE INFORMA77OV, <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? vis ❑ No KI <br /> Is this an EZIsnNG Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No u <br /> BUNNEss/FAauTY/SITENAME THREE B'S TRUCK PLAZA <br /> SITEADDRESS 14749 N.THORNTON RD SLATE# BUSINESSPMNE <br /> 209-368-8100 <br /> Cm LODI STATE zip <br /> CA 95245 <br /> BOARDOFSUPERVISOR DISTRICT LOCATIONCODE Z KEvI KEv2 <br /> McIIIrig Address,tf0/FFEREVTfram Fac//ityAddraso <br /> Attention:orCare Of(optkHre/J <br /> Mailing Address City STATE Zip <br /> SIC CODE APN# COLMENT: <br /> (0 F35- !So- z(p <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idenUf/edabove. <br /> BUSINESSNAME ADVANCED GEOENVIRONMENTAL, INC. Attention:orCare Of(opetane// <br /> Mailing Address PHONE <br /> 837 SHAW RD 209-467-1006 <br /> CITY STOCKTON STATE CA LP <br /> 95245 <br /> AccouWr.A00RE86 for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPUAN'CE ACT4VGWIBDGMENT: I,the undersigned Applicant,cerffy that I am the Owner,Operator,or Audmrized Agent of this Business,and!acknowledge that all ftatufT FEES, <br /> PE.%,tLTIts,ENFowwENTCH ,ET and/or Hot YQUKGEsassociated with this operation will be billed tome at the address identified above as thvjC O M'ADBRFSS for this site. I also cerfify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN J09Qa41s[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 /> anv 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 my representative. a �— <br /> APPLICANTNAME(PLEASE PRINT) TIMOTHY J.CUELLAR SIGNATURE <br /> TITLE PROJECT MANAGER TAX ID# <br /> Approved By Date Accounting Mice Processing Completed By Date <br /> SITE MITGATON AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY W0R ,'LANPE <br /> FEE:$ U']S2 <br /> C <br />