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SAN J�QUIN COUNTY ENVIRONMENTAL HEALTH f0ARTMENT <br /> Es >,T GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION & LOP <br /> SHADVOMEMEQR§IMLUNDIM <br /> OWNER IDS CASE# 90b(r4 >,`{5 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: <br /> CMECN/f OWNER A4CURREAm YwnLewTV EHD <br /> PROPERTY OWNER NAMe City of Ripon (209) 599-2108 <br /> FIRST MI LAST PHONE NUMBER <br /> EaMIL ADDREeB <br /> BUSINESS NAME City of Ripon Rights-of-Way kwerner@cityofripon.org <br /> OWNER HOME ADDRESS <br /> STATE LP <br /> Cm <br /> OWNER MAKINGADORESS 259 North Wilma Avenue <br /> STATE <br /> MAILING ADDRESS CITYCA <br /> Ripon zip 95366 <br /> ❑CONPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ®OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> —EPA— <br /> FACILITY INv# ACCWNTID ( PR# RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB�DTSC_EPA <br /> Jo [+zea <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑.y No <br /> 29 <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES IN No ❑ <br /> BUSINESSIFACILRYISITEIPRWECTNAME Business: Nestle USA, Inc. Facility: Former Nestle USA, Inc. Facility <br /> SURE# BUSINESS PHONE <br /> SITE ADDRESS I PROJECT LOCATION <br /> 230 Industrial Avenue <br /> STATE LP <br /> CITY RipCA 95366 <br /> on <br /> BOARp OF SUPERVISOR DISTRICT I S I LOCATION CODE <br /> S KEY./ KEY2 <br /> MAIUNG ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> wo North Braod Blvd Marie Joachim <br /> STATE ZJP <br /> MAILING ADDRESS CITY Glendale CA 91203 <br /> SIC CODE APN# M�) COMMENT: <br /> �U <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> ATTENTION:ORCARE OF (OPTAN/AL) <br /> BUSINESS NAME Environmental Cost Management,Inc. Bina ak Acharya <br /> PHONE <br /> MAILING ADDRESS 661-255-1693 <br /> 3525 Hyland Avenue,Suite 200 <br /> STATE ZIP <br /> Cm Costa Mesa CA 92626 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND CONIPLTANCE ACKNOWLEDGMENT: I,the undersigned Applieany certify that 1 am the Owner,Operator,Authorized Agen,4 or Responsible Parry and I aelmo"iedge that all PEEWIT Fecs, <br /> PENALTIES,ENFORCEarENT CHARGES and/or HOURLY CHARGES associated pith this project"ill be billed to me at the address identified above as the AccouMADDRFSS for this site. I am certify that all <br /> Information provided on this application M true and svrretl;and that all regulated activities will be performed In accordance with all appBnble SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS end STATE and/or FEDERAL I.and REGULATIONS. As the undersigned Owner,Operator,AarhorizedAgenA ar Responsible Parry for the project located above under faculty/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment Information to SAN JoAQUIN CoDl ENvTRONh6NTAL HEALTH DEPABTNLNT as soon as it M available <br /> and at the same time It is provided to me or my representative. <br /> APPLICANT NAME(PLEASEPMW) Binayak Acharya SIGNATURE <br /> TITLE Nestle Program Manager TA%ID# ECM Tax ID:20-4076378 <br /> APPROVED BY <br /> DATE ACODUNTW G OFFICE PROCESSING COMPLETED BY F�� <br /> SITE MITIGATIO AMOUNTPAID DATE OF PAYMENT P YMENTTYPE RECEIPT# CHECK# RECEIVED WORM PLANFEE:; 17� 4j II 12011 -L �I Ste- �(y/ _ G <br /> 0,N � 4� 1921-1 ' <br />