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San J.1ouin County Environmental Health Partment <br /> DATE I I S y ' 44 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> $NPDEO RflEy9 Pofl tiQt�4E�NlY OWNERID# 10`3NO UNIT IV <br /> OWNER FILE:GbwLErETREFarL4wiPROPERTY OWNER WFoRmATIoN. CHerara,OWNER eDRRRwringrot,raustmREND❑ <br /> Jerry1. Jenkins . <br /> PROPERIYOWNERNAME 2. Cftv of Ril2on 2. City of Ripon 1.(209)599-3035 Z (209)599-2M <br /> First M, Last PHoNENussfan <br /> BUSINEssNANE 1. Ripon Milling Inc. EYAILAooREss <br /> 2. Multiple Right-of-Ways within Ripon(Encroachment Permit obtained) 1. info@dendulkpoultry.com <br /> Ovmer Hlmle Address <br /> City STATE LP <br /> Owner Melling Address 1.320 South Stockton Avenue/P.O. Box 180 <br /> 2.259 N.Wilma Avenue <br /> MmUngAddriaegty 1.Ripon state 1. CA Zip 1.95366-2745 <br /> 2. Ripon 2. CA 2.95366 ��--11 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FEDAGENCY❑ OTHEROJ <br /> SITE MITIGATION_Elfin RONMENTAL ASSESSMENT--X-VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INYESTIGATIO N LOP <br /> FAcILM to INV# A/ccouGNT ID PR # LEADAGENCy:EHD__RWQCB_DTSC_EPA_ " <br /> & OS� <br /> FACILITY FILE CbMPLECETHEFIJt?L0111IR u'BUSINESS 1 FACILITY I SITE OVORmAnmr. <br /> Is this a NEW Business LocATIoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> is this an ExisnNG Business L.ocAnoN but a NEW TYPE of regulated Business? YES 0 No <br /> BUWNESSIFACILmIS1TENAME Business: Nestle USA, Inc. Facility: Former Nestle USA,Inc.Facility <br /> SmriooREss 230 Industrial Avenue surrE# BBt SIN SPHOME00 <br /> Cm Ripon STATE ZIP <br /> CA 95366 <br /> 80AROOFSUPERVISORDISTRIM OCATONCODE kEY1 <br /> Mailing Address iF MrIftmet3eilRyAddiress Attention:ca-Care Of(bpffiam ) <br /> 800 North Brand Blvd Michael Desso <br /> Mailing Addre ay Glendale STATE ZIP <br /> CA 91203 <br /> SICCOOE APN# DOMMEM: <br /> THIRD PARTY 1111IN411116 INFO: Complete if Billing Party is different from Property Owner or Facility Operator ideqjWPff above. <br /> 6UEAdd <br /> Attention:wCare Of j <br /> MePHONE <br /> Cm STATE ZIP <br /> ._ ____._ for fees and eherges OWNER FACT BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACU 10AVLEDGNEW.' 1,the undersigned Applicant,certify that 1 s m the Owner,Operator,or.dudomired Agent of this Business,and I acknowledge that all PER1tfTFEEe, <br /> mAtTIES,FAEiinRcsst&YT cm.4RGE$aadfor HOMLY f11ARGES associated with this operation will be baled to me at the address Identified above a5 the ACrWiTAnORG4Y for this Site. I she certify that <br /> n11 Information provided on this application is true and correct;and ural all regulated activities pili be performed in accordance with all applicable SAN JOAQUIs Comvly Ordhmnee Codvt and/or <br /> Stands rds and STALE and/or FEDERAL.Laux And Regulations, As the undersigned owner,operator,or agent of the property I rated of the abovefacilitylate address,1 hereby aothoritc the release of <br /> any and ng tomla,and environmental moessewin infarmmlon to SAN JOAQUIN COUNTY ENV IRONVI ENTAL HEALTH DEPARTMENT as mon as it IS available and at the same Owe It is <br /> provided mar myrepresenmtive. <br /> APPLICANN TNAME(PLEASE PRIM) Michael Desso SIGNATURE � <br /> TITLE Director,SHE TAX ID# Federal ID#95-1572209 <br /> A-P vena Date popouaEng of on,Prawsaing Complet" pato <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYNENi TYPE RECEIPT# CHECK# RECEIVED By WORN PLAN Pe <br /> FEE:$ Z^&-o <br />