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San jf#4uin County Environmental Health �!"Nartment <br /> cc » GREEN FORM <br /> DATE i1 14 (g MASTER FILE RECORD INFORMATION SFR SITE MITIGATION &LOP <br /> O` 0 UNIT IV <br /> N �O A r,�og EH0 W-QMA OMSR I OJt <br /> OWNER FILE:0OMPLEVETFIE'F8V PROPERTY OWNERfict"wMATION: Ga �OwNERE aREN1ETONFYENmCEHD� <br /> erry 1.Jen ins 1,(209)599-3035 2. (209)599-2108 <br /> PRUPEer,OMERNAME 2. Cit Of Ri n 2. it Of RI O <br /> MPx <br /> Frs 1 Last tmENUMI>ER <br /> E+eaaADDlrtss <br /> BUSINEEBNAME 1.Ripon Milling Inc. 1. info dendulkpouitrY.com <br /> 2. MUlti le Right-of-Ways within Ri an(Encroachment Permit obtained @ <br /> Decrier Honte Address <br /> $FATE ZJF <br /> City <br /> wner Melling Address 1.320 South Stockton Avenue/P.O.Box 16D <br /> O <br /> 2.259 N.Wilma Avenue state 1 CA qp 1.95366-2745 <br /> Malling AdcheIN City 1.Ripon 2.CA 2.95366 <br /> 2.Ri on <br /> CORPORATWN❑ INDIVIDUAL❑ <br /> PARTNERSHIP❑ FWAOENCT❑ OTHER® <br /> SITE MITIGATION_ <br /> ERUIR RMI RIITAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION—LOP <br /> — <br /> SITE <br /> ID INvtt A/Cct lal�NjTID PR e IG L Y LEAD AGENCY:EHD_RWOC8_DTSC_EPA_. <br /> 6p `-T O Vs� <br /> FACILITY FILE jFMpLLWTHEFott.@CWW BUSINESS f FACILITY 1511 E INFORMATTOl . <br /> Is this a NEW Business LOCATION not previtwsly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 91 <br /> No <br /> Is this an EwsnNc Business LOCATION but a NEwTTPE of regulated Business? <br /> YES ❑ 12 <br /> Bust"MaFlifiRINAME Business:Nestle USA,Inc. Facility Former Nestle USA,Inc.Facility <br /> SURES BUSINESSPHONE <br /> SFMAWKSS 230 Industrial Avenue 818 549-6000 <br /> STATE ZIP <br /> CITY Ripon CA 95366 <br /> SOARDO SUPERYISOROSTRiCT OCATIONC REyT <br /> Attention:ca-Care Of(aptl6nsO <br /> Mailing Address' T"rrom Facdtty'Addh00 North Brand Blvd Michael Desso <br /> STATE ZIP <br /> Mailing Addre ity, Glendale CA 91203 <br /> Sic CDDE APNS CoMME"T' <br /> Owner or Faci tty Operator ide above. <br /> THIRD PARTY B INO INFO:Complete if Billing Party is differentfrom Property <br /> Attention:wCare Of <br /> aUSINESSNAME <br /> PHONE <br /> Meiling Address <br /> STATE ZIP <br /> Cm <br /> LfpiOVNTAUDR('3S for fees and charges OWNER <br /> FACI BUSINESS THIRD PARTY BILLING <br /> Gil t'G AND Co fru NCE ACKNOWUDS:wENT: 1,the undersigned Applimnt,certify"that Iam the Owner,Ofurn+er,or ANMorised Agent ofthis guslneas,and1acknowledgeh, allso cardly that <br /> PL.yALT)ET,EN£ORCElIFNTC'NARGa andlor NOLTLYCIIeRGE,associated with this operation will be billed to me at the address identified above as the ACCOUyrADDRESY for this dte. 1 also mrdlV that <br /> nil information provlded on tills Applimdon Is tme,and correct;and that all regulated ocdvidea will be performed in accordance wNh all applicable SAN JOAoniN Coumv Ordinance Codle andeor <br /> owner,aimmmr,or agent of the property I a ded at the above mcgiWsite address,I hem-by authorize the rekase Of <br /> Snndards ami STATE anNar FEDERAL La"anti Regulations. As the onderslgndl <br /> any and all results and e"chmmatnted aasm land inferaatian to SAN JOAQUIN COUNTY ENYIRONT7F.NTA1.HEALTH DEPARTMENT as.Man as�t is avulahle alai at the same date it is <br /> provided to lest or my represenmtlm. <br /> APPLICANT NAME(PLEASEPRINT) Michael Desso SIGNATURE <br /> � <br /> TITLE <br /> ID#E Director,SHE Federal ID#95-1572209 <br /> Ap vetl By Date <br /> All ouoting Ofliae Pmem,,"Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE Or PAYMENT PAYMENT TYPE RECEIPT,C GNECKe RECEIVED RY WO7RR PGtAL/N.P�E <br /> FEE:$ <br />