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San Joaquin County Environmental Health Department <br /> DATE <br /> MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION &LOP <br /> SHAPED AREAS PHO USE ONLY OWNER ID# CASES UNIT IV <br /> OWNER FILE:COMPLETE PROPERTYOWNERIRESPONSIBILE PARTY/NFORMA71OW. ctrecNNOWNER CURRENTLy0siftENYTHEND <br /> Q <br /> PRO MWOWNERNAME Carol and Albert Scannacino ( )209-931-3570 <br /> first Ml Last PHONE NUMBER <br /> Bmm.NAME ,....L ADDRESS <br /> Scannavino Properties I <br /> Owner Home Address <br /> city BTATE Tip <br /> Carrier Malikp Addm. <br /> 5463 E.Cherokee Lane <br /> MMNIkg Addroas CitySdV ZdP <br /> Stockton CA 95215 <br /> Q CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL As5E5SMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT IDPROIROO ASSIGNED EMPLOY EE LEAD AGENCY:EHD_RWOCB_DISC_EPA_ <br /> 00 ABh� 00-07 7 40,;r raA <br /> FACILITYFILE: COMPLETE BUSINESS/SITE/PROJECT/NFORMAT/ON: <br /> IS this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No O <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES BE No ❑ <br /> BUSINESS/FACILITYISITEWROJECTNAME Former ARCO Service Station No. 0595; RB Case No. 390411; LOC Case No. 0707 <br /> SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 6100 North Highway 99 <br /> CITY STATE Tip <br /> Stockton CA 95212 <br /> BOARD OF SUPERVISOR DISTRICT 0� LOCATION CODE QI KEYI NEY2 <br /> Mailing Address IfOIFFERENTfiam F.aflfy Address Attention:or Care Of(option/) <br /> Mailing Address City STATE ZIP <br /> $IC CODE APN# COMMENT: <br /> 08704034 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orResponsible Party identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> ARCADIS L 5. <br /> Melling Address PHONE <br /> 101 Creekside Ridge Court,STE 200 916-786-0320 <br /> CITY STATE LP <br /> Roseville CA 95678 <br /> AQGQUyLAaQAESE for fees and chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the ordersgned Applicant certify dui 1 am the Owner,Operaan,Asrhorked AReN4 or Rapornible P",and I aciespwkdge lent dl PERMIT FEES, <br /> PENALTIES,ENFDRC'EHEM'CHARGES and/or NouRLYC'NARGF_s assocutod with this project will be billed tome at the Address identified shave as the ACCouN AMRE.SS for this site. I also certfy that all <br /> information provided on this application is true and correct; and that all regulated acmitrs will be performed in accordance with all applicable SAN JOAQum COUNn'Ordinance Codes and/or <br /> Standards and STATE:and/or FEDERAL Laws and Reguladmre. As the undersigned Owner,Operator,Author¢etl Agent or Resprlmible Party far the pmjM located above ander facilihlsi a address,1 <br /> hereby anchorite the release of any and all multi,reports,and other environmental assesshnent information to SAN JOAQI'IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENI'as soon as it <br /> is available and at the same lime it is provided to me or my representative. J <br /> APPLICANT NAME(PLEARE PRINT) Megan Smoley SIGNATURE fI 'A� <br /> TITLE Senior Geologist TAxlO# ARCADIS TAX I.D. # 57-0373224 <br /> Approved ey Gate Accounting Once Processing Completed By Data <br /> $ITE MITIGATION AMOUNT PAID DATE Or PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY <br /> WORK PuNPE <br /> FEE:: 3s <br />