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SAN JOAr)UIN COUNTY ENVIRONMENTAL HEALTH nEPARTMENT <br /> DATE mk..SER FILE RECORD INFORMATION �...-R" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/F OWNERS CURRENTL Y ON FILE WITH EH <br /> PROPERTY OWNER NAME Brent KrUSC ( 1 209-577-6690 <br /> FIRST M/ LAST \PHONE NUMBER <br /> BUSINESS NAME 801 Kettleman Investors PTP E-MAIL ADDRESS <br /> OWNER HOME ADDRESS <br /> CITY STATE LP <br /> OWNER MAILING ADDRESS <br /> 1308 Kansas Ave#6 <br /> MAILING ADDRESS CITY STATE ZIP <br /> Modesto CA 95351 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY Q RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD /` RWQCB_DTSC_EPA <br /> -10 k <br /> FACILITY FILE:COMPLETE BUSINESS/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 ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE/PROJECT NAME <br /> Wendy's Restaurant <br /> SITE ADDRESS/PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 801 East Kettleman Lane <br /> GLOdI STATE ZIP <br /> CA 95240 <br /> BOARD OF SUPERVISOR DISTRICT "I LOCATION CODE 1 KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> $IC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Partner Em1lncerinff and Scicnce. Inc. ATTENTION:ORCARE OF (OPTIONAL) Samantha Harris <br /> MAILING ADDRESS i I i4 Torrance 130ule\ard.Suile 200 PHONE <br /> 310-615-4500 <br /> Cm Iorrancc STATE CIN ZIP 9U;ol <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS[:) THIRD PARTY BILLINGE] <br /> BILLING:%ND CONPLIAN('t:ACKNU\c LP:nG\11C N'1: I.the undersigned Applicant.certify that I am the Owner.Operator.:luthorked:Igent,or Responsible Part)-and I acknowledge that all PERMIT FOES, <br /> PE.\ILni.,s.E.:\FYIRCIiSIEN7 C71IRG1.8 and/or 1101*RL)('//IRGES associated with this project will be hilled to me at the address identified above as the.ICC01 AT ADDRESS for this site. I also certify that all <br /> information provided on this application is true and correct:and that :Ill regulated activities will be performed in accordance"ith all applicable SAS.10AQLIN COt NTN.ORD[NAVCE CODES and/or <br /> STANDARDS and Sr:\Tt:and/or Ft:DERAL Laws and Rtx;rl.m ioNs. As the undersigned Owner,Operator,:utbarked/ (gent.or Responvib/e Pari-for the project located above under facilitdsite address. <br /> hereb\authorize the release of an and all results.reports.and other environmental assessment information to SAN.10:\Qt V,COUNT) F.5\'IRO\\IENrA1.IWALF11 DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Salflanlha I larris SIGNATURE <br /> TITLE SCI110r Project Manager TAx ID# '0-8264379 <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT <br /> TT7PAID DATE OFPPAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK LAN PE <br /> FEE:$ 3`7,T -375-5 ?—Cl.(1-V( �!lj�.e< /5-2-<:�,3 l.C7Ll?J /L <br />