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SAN JUIN COUNTY ENVIRONMENTAL HEALTH MARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> ��JJqq SITE MITIGATION & LOP <br /> SHADEDAREAa FOREHOLIMONLY OWNER IDM LASER 'JR Cf({ 1S-l ✓ UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHEM IFOMAMERAF CURRENTLYONFice WITH EHD El <br /> PROPERTY OWNER NAME City of Ripon (209) 599-2108 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME EYAIL ADDRESS <br /> City of Ripon Rights-of-Way kwerner@cityofripon.org <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNERMAIUNGAODREee 259 North Wilma Avenue <br /> MAIUNGADDRESSCm <br /> Ripon STA <br /> CA �P 95366 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ®OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY IDM INV# ACCOUNT IDPRM ROM ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB�DTSC_EPA <br /> L� GYM o�II JO I+uv <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES IN NO ❑ <br /> BUSINessIFACILITYISrrEIPROAEOT NAME <br /> Business: Nestle USA, Inc. Facility: Former Nestle USA, Inc. Facility <br /> SITE ADDRESS/PROJECT LOCATION SURER BUSINESS PHONE <br /> 230 Industrial Avenue <br /> Cm STATE ZIP <br /> Ripon CA 95366 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE _� KEY1 KEY? <br /> MAILING ADDRESS.IF DIFFERENT FROM FACILITY ADDRESS ATTENRON:ORCARE OF(OPr10AMt) <br /> 800 North Brand Blvd Marie Joachim <br /> MAILING ADDRESS CRY STATE LP <br /> Glendale CA 91203 <br /> SIC CODE APNM Row COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS HAM Environmental Cost Management,Inc. ATTENTION:ORCARE OF (OPTIONAL) <br /> Binayak Acharya <br /> MNDND ADDRESS PHONE <br /> 3525 Hyland Avenue,Suite 200 661-255-1693 <br /> CTry Costa Mesa STATE ZIP <br /> CA 92626 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRDPARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicam,certify that 1 am the Owner,Operator,Authorized Agent,or Resposcible Parry and 1 acknowledge that all P£RwTFErs, <br /> PENACTJF$ENFoRCEnfEATCHARGES and/or HOuuY CHARGES associated with this project will be billed tome at the address Identified above as the ACCINIMARORE$$for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operarar,AuthorizedAgent or Responsible Party for the project located above under faculty/she address,I <br /> hereby authadtt the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENW RONMENTAL HEALTH DEPARTNIE.NT IIS Soon SS It Is available <br /> and at the same time it is provided to me or my representative. <br /> APPUCANTNAME(PLEASEPRINT) Binayak Acharya SIGNATURE <br /> TIDE Nestle Program Manager TAX IDM ECM Tax ID:20-4078378 <br /> APPa0VE0 BY DATE ACC ,NO OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITTIIGATIO AMHE <br /> COUNT PAID DATE OF PAYMENT P YMENTTYPE RECEIPT# CCK# RECEIVED BY WORK PLAN PE <br /> FEE:$ J�� 'l 2j II 120112 VI Sd a9Lo <br /> 0 tt * ) 92" C1 I <br />