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0 0 <br /> San Joaquin County Environmental Health Department <br /> DATE ,1 y , H MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> SH"EDARERS FOR EH!?USE ONLY OWNER IDD D / UNIT IV <br /> OWNER FILE:C[IMPLETETHE'Fi ULOWING PROPERTY OWNER lhiOAMWnow. CN[ W CWNERMRRImnY= WM'EHD L1 <br /> 1. erryen Ins <br /> PIWPERTYOWNER NAME 2. City of RiDon = I 2. Ctv of Ricron 1.(209)599-3035 2.1(209)599-2108 <br /> Fast Mf Last PNONENUMM <br /> BUSINESSNAME 1. Ripon Milling Inc. E MAL w <br /> 'Encroachment Permit obtained 1.info@dendulkpoultry.com <br /> Dynner Hama Atkin <br /> City / / / STATE LP <br /> Owner Melling Addl ((�J v 0. Box 180 <br /> Mailing Address Cit) state I. CA zip 1. 95366-2745 <br /> 2 CA 2. 95366 -':.raf _ <br /> CORPORATION G INONIDUAL❑ PARTNERSHW❑ FEDAGENCY❑ OTHER IJ <br /> SITE MITGATION_ENVIRONMENTAL ASSESUAINT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIOATIoN_LOP._ <br /> fACIUIY ID/ INV# AOOOMMID ROR I AtMe I LEAD AGENCY:EHD_RWpCB_DTBC_EPA <br /> 61+ 1 (,7(8 90s-f <br /> FACILITYFILE GOMPLETETHE FOELGWNW BUSINESS I FACILITY/SITE INFORMATION- <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yes ❑ No 91 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? Ys ❑ No <br /> BtImNEsetFACILT'iSneNAME Business:Nestle USA, Inc. Facility: Fortner Nestle USA, Inc.Facility <br /> SITEAOORESS EUIIEM BUNNEBS PHONE <br /> 230 Industrial Avenue <br /> 818 549-6000 <br /> CITY Ripon STATE 7JP <br /> CA 95366 <br /> BOARD OF SUPERVISOR DISTRIC LOCATMNOOUE KERt NEVI <br /> Mailing Address rf ERENT from Facility Address Albentlan:arCare Of(ttptlMely` <br /> 000 North Brand Blvd Michael Desso <br /> Melling A Ease, Glendale City STATE ZIP <br /> CA 91203 <br /> sic F APNa COMMENT: <br /> THIRD ARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified Ave. _ <br /> BUSIN AME Attention:orCere Of(optionaly <br /> Meiling AddrePHONE <br /> Cm S ZIP <br /> ACCOUNTA13DRESS for fees and charges OWNER FACIUTYWUSINESS THIRD PARTY BILLING <br /> BILLITti N,ND CO)IPI.LWCE ACNVOI$LEM,IIENT: 1,the undersigned applicant,certify that I am the Owner,Operamq or AN@oAud Agent of this Business,and 1 acknowledge that all PERvO FEES, <br /> PY,LLTmv,E.YFORcevEATCIIARGESand/or HOGRLrCu,RLEs.owwmvA with this operation Will be baled lame at the address Identified above as the AclouATAINN,farthissloe. iDianaerdh'that <br /> all Information provided on this application Is Nur and correct;and that all regulated Activities will be performed In accordance nigh ell applicable SAI JOAQR 11 C14'Nn'Ordinance Codes and/.r <br /> Standards and Stan:and/or FEDENM.Laws and Regulations. As me undrnignsd.wm,,,apemwr,nr agent of the property located al the above facilltylshe address.I hereby amhodze the release of <br /> any and all results and environmental assessment Information to SAN JOAOUIN COUNTY ENVIRONMENTAL HFAL I II OF.RYRTMF.NT m won as N N rveiloM1le and nl the semr time b is <br /> APPLICANT NAME(PLEASE PRINT) Michael Desso SIGNATVPE � <br /> TITLE Director,SHE TAIf IDS Federal [D#96-1572209 <br /> Approved By Data gcco..Ing Office Prooeesiog ComplatedB / Date �z <br /> reveffs MITIGATION AMOUNT PAID DATE Of PAYMENT PAYMENT TYPE RECEIPTR CNECKe RECEIVED BY WORK PUN PE <br /> reviii .2 q�v <br />