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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT EIVED <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> r "MFR"-GREEN FORM .SUN 12 2017 <br /> DATE OR END USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS C11"V4ERWA8HD E] <br /> PROPERTY Dave I I Johnson PHONE <br /> OWNER NAME FIRST Mf LAST <br /> BUSINESS NAME Scannell Properties 220 LLC E-MAILADDRESS <br /> OWNER HOME ADDRESS ATTENTION:OR CARE OF(OPr/ONAL) <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS 800 East 916th Street <br /> MAILING ADDRESS CITY Indianapolis STATE IN 7JP 46240 <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> X1 ENVIRONMENTAL ❑ EH LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 296013526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS 1 SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES XI NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO IX <br /> BUSINESSIFACILITYISITEWROJECTNAME Vacant land / APN: 221-210-20 <br /> SITE ADDRESS I PROJECT LOCATION Vacant land 32! Res A1L� BUSINESS PHONE <br /> CITY Manteca Y STATC CA LP 95336 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY') KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME Terracon Consultants, Inc. ATTENTION:ORCARE OF (OPnONAL) Scott Gable <br /> MAILINGADDRESS 50 Goldenland Court, Suite 100 PHONE 916-928-4690 <br /> CITY Sacramento STATE CA ZIP 95834 <br /> ACCOUNTADDRESSToSEND FEES AND CHARGES-. OWNER❑ FACILITYlBUSINESS❑ THIRD PARTYBILLINGIX <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Owner, Operator,Authorized Agent, <br /> or Responsible Parry and I acknowledge that all PERMIT FF_Fs,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNTADDRFss for this site.I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUN'T'Y ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JO umCOUNTY E I NMENTAL <br /> HEALTH DEPARTMEn'r as soon as it is available and at the same time it is provided tome or my r e tam <br /> APPLICANT NAME(PLEASE PRINT) Scott Gable SIGNATURE <br /> TITLE Environmental Department Manager/ Project Manager TAXID0 <br /> FA#: OWNER ID#: ASSIGNED T0: <br /> A ooz a 1 DW6ozz�70vTTCCOUNTS: A2oo�7, 8 <br /> PR#: 9 7 ACCOUNTING COMPLETED BY: � DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />