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e a SAN J�QUIN COUNTY ENVIRONMENTAL HEALTHPARTMENT <br /> " n GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> SHADEDas OREHDUSEONLY =OWNERIDN CASEY SfabQ4 '`q`I UNIT IV <br /> se <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNECKIFOWNERMCURRENTLYONF/LEwrHEHO El <br /> PpOPERTY OWNER NAME City of Ripon 1 1 (209) 599-2108 <br /> FAST MI LAST PHONE NUMBER <br /> EiuuLADDRESS <br /> BUSINESS NAME City of Ripon Rights-of-Way kwerner@cityofripon.org <br /> OWNER HOME ADDRESS <br /> STATE ZIP <br /> CITY <br /> OWMRMMUNGAWRESS 259 North Wilma Avenue <br /> MAIUNG ADDRESS cm Ripon STATECA ZIP 95366 <br /> ❑CORPoRArION ❑INDIVIDUAL ❑PARTNERSHIP ❑GWERNMENT AGENCY ❑RESPONSIBLE PARTY MOTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> COUNTID PRY �DTSC_EPA_ <br /> FACILm ID INVY AIJB <br /> CB <br /> G4(a ey <br /> Ifua <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO N <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORN? YES I2q NO ❑ <br /> BUSINESS/FACIUTY/SREIPROJECTNAME Business: Nestle USA, Inc. Facility: Former Nestl6 USA, Inc. Facility <br /> SURE# BUSINESS PHONE <br /> SITE ADDRESS I PROJECT LOCATM7N <br /> 230 Industrial Avenue <br /> STATE LP <br /> Cm Ripon CA 95366 <br /> BOARD OF SUPERVISOR DISTRICT S LOCATION CODE KEY T KLV2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> Marie Joachim <br /> STATE ZIP <br /> MAILING ADDRESS Cm <br /> Glendale CA 91203 <br /> SICCWE APNY COMMENT: <br /> Rom <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> ATTENTION:OIPCARE OF lbon0NAL) <br /> BUSINESS NAME Environmental Cost Management,Inc. Bina ak Aa a <br /> PRONE <br /> MAILING ADDRESS <br /> 3525 Hyland Avenue,Suite 200 661-255-1693 <br /> STATE LP <br /> Cm Costa Mesa CA 92626 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTYBILLING® <br /> BILLING AND CGMPU NCE ACN.YGwLEDGMEHT: I,the undersigned Applicant,certify that 1 am the Owner,Operamry Authorized Agent,or Resporuih/e Party and I acknowledge that ell PEm i PEFS, <br /> PENALTIT,ENFORCEMENT CHARGET and/or JYQCRLI,CHARGER associated with this protect will be baled to me at the address Identified above as the AccouN AalnuzT for this site. 1 also certify that all <br /> Information provided on this application Is true and correct;and that all regulated activities will he performed in accordance with all applicable SAN JOAQUIN COUNT,ORDNANCE CODES and/or <br /> STA mARms and STATE and/or FEDERAL Laws and REGULAnON& As the undersigned Owner,Opera cr,AuthorI Agem;or Rerponrible Party for the protect located above under faculty/site address,I <br /> hereby tuthorbe the release of any and an results,reports,and other envimmnental assessment Information to SAN JOAQDIN Cousry EWHRGNatENrA REALTH DEPARTMENT as stores it is available <br /> and at the same dme it Is provided to me or my represenmtive. <br /> APPucANTNAME(PL.EASEPRINT) Binayak Acharya S1V� � <br /> Tri Nestle Program Manager TAI ECM Tax ID:20-4078378 <br /> APPIIOVFD BY DATE <br /> ACOOtINnNOOFflCEPROCESSINOCWPLETEDaY DATE <br /> SITE MITIGATIO AMOUNT PAID DATE OF PAYMENT PAYMEt/T TYPE RECEIPTY CHECNY RECEIVED BY ala PLANPE <br /> FEE:$ 3.J� /.0 I SIv `� 7 <br /> /� 1 <br />