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SAN JOAr)IJIN COUNTY ENVIRONMENTAL HEALTH DFPARTMENT DACE MA.. .ER FILE RECORD INFORMATION "M. .�" GREEN FORM SITE MITIGATION & LOP SHADED AREAS FOR EHD USE ONLY OWNER ID#h 1.'� /j y CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER//RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLYONF/LEWITH EHD PROPERTY OWNER NAME Brent KrUse \ 1 209-577-6690 FIRST MI LAST \PHONE/NUMBER BUSINESS NAME 801 Kettleman Investors PTP E-MAILADDRESS OWNER HOME ADDRESS CITY STATE ZIP OWNER MAILING ADDRESS 1308 Kansas Ave#6 MAILING ADDRESS CITY STATE LP Modesto CA 95351 ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ©RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY HIW PIPELINE INVESTIGATION LOP_ FACILITY ID# INV# ACCOUNT ID PR#/RO# �[tj#�OYEE LEAD AGENCY:EHD X RWQC13_DTSC_EPA D22 Z✓�� A4D4ID 7 T A�fM)4� FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No ❑ BUSINESS/FACILITY/SITE/PROJECT NAME Wendy's Restaurant SITE ADDRESS/PROJECT LOCATION SUITE# BUSINESS PHONE 801 East Kettleman Lane �ITMLodi STATE ZIP I CA 95240 BOARD OF SUPERVISOR DISTRICT M LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY STATE ZIP 11 SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Partner Engineering and Science.hlc. ATTENTION:ORCARE OF (OPTIONAL) Samantha Harris MAILING ADDRESS 2154 Torrance Boulevard,Suite 200 PHONE 310-6154500 CITY Torrance STATE CA ZIP 90501 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® Bn.I.INc:)ND ContrLlANce r1CI:N0)y LEDGpteN'T: L the undersigned Applican4 cerci fv that I am the Onmer,Oparatnr,:Irrthm'i:.ed:Igent,or Responsible Pnr!1'and I acknowledge that all PERMIT FEES, PE:a;ILrrrs,E.)'ForrcE,vE:rTCrLIRCEs and/or 1101:RLr C11IRGF.S associated with this projecl%rill be billed to me at the address identified above as the,cent ATADDRE.SS for this site. I also certify that all information provided on this application is true and correct:and that all regulaled activities hill be performed in accordance with all applicable San JOAQcIN COI:NT)'ORDINANCE Coots and/or STANDARDS and STATE and/or FEDERAL Lam and REGULATIONS. As the undersigned Ulmer,OperRfOr,Anthoriced:lgcitt,or Responsible Pagy for the project located above under facilit'%site address. hereby authorize the release of any and all results•reports.and other environmental assessment information to SAN JOAQUIN COUNT)-EN)TRONMENTAL I-IEAL'rIl DEPARTMENT as soon es it is available and at the same lime it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Samantha 1-lairis SIGNATURE TITLE Senior Project Manager TAx ID# 20-8264379 APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WgSK P PE FEE: 31)5 175 �' 1"f lj�� ( ��O� I.00t?/• /rj`(7]