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San JoMin County Environmental H�alfff-U�rtment <br /> 3 <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHM0 EH SE CASEN UNIT IV <br /> OWNER 104 ter',.. <br /> OWNERFILE:COMPLETETH,EFOLLOW/NG PROPERTY OWNER INf'ORMATIDN.' CNBCKIF OWNER CURRENTLYONFILBH?THEND� <br /> LPPROEOwNELambert (63p 963-4090 <br /> FfrsfM/ Las[ PHDNE NUMBER <br /> NAME R.F. Land E-MAILADDRESS <br />` <br /> Owner Home Add <br /> res" 405 West Pine Street <br /> E city 'Lodi STATE CA z�P 95240 <br /> E Owner Mailing Address same <br /> Malting Address City <br />{`r <br /> same, State Zip - <br /> IFh <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP <br /> ❑ FED AGENCY© OTHER�] <br /> k SITE I411TIaAT1ON_ENVIRONMENTAL ASSESSMENT_ VOLUNTARY CLEANUP_WATER QUALITY HW PIPEUNB INVE3TIQATION_LOP <br /> FACILITY ID A INV# ACCOUNT le PR RO/ ;5 c. �r�[ rr' xx <br /> 3�33c7 rte Bit,::dY� -�,u/ _.,4n7t�.rL`�'F <br /> FACILITY FILE COMPLEM rHEFOLLoww BUSI NESS FACILITY-SITE INFoRMAwN., <br /> Is this a New Business LOBATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs.❑ No <br /> Is this an ExisTima Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No$] <br /> BuslNEssIFACIL[TYlSiTE NAME <br /> FORMER RIPON FARM SERVICE (RF LAND); <br /> SITE ADDRESS 932 EAST FRONTAGE ROAD SUITE#- BUSINESS PHONE <br /> CITY RIPON �IE STATE Cep 95366 <br /> BOARD OFSUPERVMOADISTRICT LocAT10N.CODE Keri i�G Kart <br /> Mailing Address WDIFFERtcWfram FavilityAddress Attention:orCare Of(optional) <br /> I� <br /> Malling Address City STATE Zip <br /> SIC CODE API!# COMMENT: � <br /> THIN PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacillty Operator identified above. <br /> BUSINESS NAME RF LAND C/O PAUL LAMBERT .'F,Attatltioll:orCare Of (optional) <br /> Mailing Address 405 WEST PINE STREET PHONE 630963-4090 <br /> Cm F-I-PQN LOOT V*1 !-g7�lL STATE CA Zip. 95 <br /> for fees and charges OWNER FACILITYJBUSINESS THIRD PARTY BILLING <br /> BTLLITiG ANA COMPL[ANCE AC"()WLEDCMENT: t,the undersigned Appllc=4 certify that I am Ilse Owne,Operator,or Authorized Agent of this Buslness,and I acknowledge that all PERnnrFe Es, <br /> PENALTilm,ENFORCEMENTCH4RGE$and/or HOURLYCimAcES associated with this operatlan will be billed tome at the addressIdentiiTcd above as the AC_ CWVT.ADDResS for this site.I also certify that all <br /> information provided on this application is true and correct,and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDEPAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby auftrize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) WILLIAM LITTLE EASE E <br /> TITLE .AGENT TAX ID;# <br /> Approved By Data Accounting Offlee Processing Completed By,,L - Date 3d }Z <br /> SITE MITigAT10N AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT ta! �rCHECK D, RECEIVED BY Wdi�ik P <br /> FEE: <br /> r <br /> j <br />