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SAN J*UIN COUNTY ENVIRONMENTAL HEALTH O4RTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" 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 IF OWNER IS CURRENTL Y ON FILE W/TH EHD <br /> iamond Pet Food Processor <br /> PROPERTY OWNER NAME f Ripon, LLC (209)824-4640 <br /> FIRST Ml LAST PHONE NUMBER <br /> BUSINESS NAME Diamond Pet Food Processors E-MAIL ADDRESS <br /> of Ripon, LLC <br /> OWNER HOME ADDRESS <br /> 942 S. Stockton Ave. <br /> CITY Ripon STATE ZIP <br /> CA 95366 <br /> OWNER MAILING ADDRESS Same <br /> MAILING ADDRESS CITY STATE zip <br /> 0 CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY X HW PIPELINE INVESTIGATION__LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD-RWQCB_DTSC_EPA <br /> W 1271,j /3Q cx�2!'�`� R $r 9Z �OFfv"'y <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 [2f <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> BUSINESS/FACILITYISITE/PROJECT NAME Diamond Pet Food Processors <br /> of Ripon, LLC <br /> SITE ADDRESS I PROJECT LOCATION 942 S. Stockton Ave. SUITE# BUSINESS PHONE <br /> CITY 'R/ipon STATE zip <br /> BOARD OF SUPERVISOR DISTRICT Oy LOCATION CODE 0 KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> ffDE_ <br /> APN# COMMENT: <br /> �5 _ 3` 0-0 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Lawrence & Assoc. ATTENTION:OR CARE OF (OPTIONAL) <br /> MAILING ADDRESS 3590 Iron Court PHONE (530)275-4800 <br /> CITY Shasta Lake STATE CA ZIP 96019 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[] FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Re.%ponsible Party and 1 Acknowledge that all PERMI%'FEES, <br /> PENAL77Es,ENFORCEMENTCHARGESand/or HOURLY CLIARCES associated with this project will be billed to me at the address identified above as the ACCOUN"1'ADDRESS for this site. 1 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 FEDERAL Laws and REGULATIONS. As the undersigned(honer,Operator,Authorized Agent,or Revponvible Party for the project located above under facility/site address,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEA DEPARTMENT DEPARTMENT as soon as it is available <br /> and at the same tine it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) David L. Kirk for Lawrence & Assoc. SIGNATURE <br /> TITLE Vice President TAxID# <br /> APPROVED BY I DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ �'' <br /> Fa I tD,� <br />