Laserfiche WebLink
0 • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 11/15/2013 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IO# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IFOWNERISCURRENTLYON FILE wtTH EHD <br /> PROPERTY OWNER NAME Ryan George /209) B33-5383 <br /> FIRsr M/ LAST PHONE NUMBER <br /> BUSINESSNAME Prologis, Inc. E-MAILADDRESS <br /> rgeorge@prologis.com <br /> OWNER HOME ADDRESS <br /> Business 17284 West Commerce Way <br /> Cm <br /> Tracy STATE ZIP <br /> CA 95377 <br /> OWNER MAILING ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> ff CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION­ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# ACCOUNT IO PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB OTSC_EPA <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: M <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES In No E,] <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No LJ <br /> BUSINESS/FACILRYISITEIPROJECTNAME Nestle Direct Store Delivery Company <br /> SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 1351 Dupont Court 209-824-8343 <br /> CITY Manteca STATE CA ZIP 95336 <br /> [B.ADISTRICT LOCATION CODE KEY1 KEYZ <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> --][SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Geosyntec Consultants, Inc. ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILINGADDRESS 3043 Gold Canal Drive, Suite 201 17-ONE 916-63'7-8046 <br /> CITY Rancho Cordova STATE CA LP 95670 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BI IAJNG AND COMPLIANCE ACKNOWLEDCM ENT. [,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERAtit'FEES, <br /> PENALTIES,EN£ORCEVENT CHARGES and/or HOURI.Y CIIA ROES associated with this project will be hilted tome at the address identified above as the ACCOUNT ADDRESS for this site. 1 also certify that all <br /> information provided on this application k true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN Ct VTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.As the undersigned()wlter,Operator,Authorized Agent,or Responsible Party for the project locate) I v'e under facility/site address,I <br /> hereby aothorim the release of any and all results,reports,and other environmental assessment information to SAN AOAQUIN COl2,5,,X <br /> Y ENYIROV�f EVL4L1FiLT11 D '.Ut wf F•\7 as soon as itis available <br /> and at the same rime it is provided to me or my representative. � <br /> APPLICANT NAME(PLEASE PRINT) Joe Niland (Geosyntec; Agent for Nestle) $IGN#T'URE <br /> TITLE principal TAxID# 59 23S 13 <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED6Y DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />