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SANOQUIN COUNTY ENVIRONMENTAL HEALTHRPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# <br /> UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CHRRENTL Y ON FILE WITH EH <br /> Diamond Pet Food Processor <br /> PROPERTY OWNER NAME f Ripon, LLC ( ) (209)824-4640 <br /> FIRST M/ LAST PHONE NUMBER <br /> BUSINESS NAME Diamond Pet Food Processors E-MAILADDRESS <br /> of Ripon, LLC <br /> OWNER HOME ADDRESS <br /> 942 S. Stockton Ave. <br /> CITY Ripon STATEZIP <br /> CA 95366 <br /> OWNER MAILING ADDRESS Same <br /> MAILING ADDRESS CITY STATE ZIP <br /> L'J 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 PR#1 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB DTSC_EPA <br /> AdDlz75� .D02-1 ID p�I V, Jv({ati <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No [� <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESS/FACILITY/SITEIPROJECTNAME Diamond Pet Food Processors <br /> of Ripon, LLC <br /> SITE ADDRESS I PROJECT LOCATION 942 S. Stockton Ave. SUITE# BUSINESS PHONE <br /> CITY Ripon STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT o q LOCATION CODE KEY1 LKEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# JrOMWENT- <br /> THIRD <br /> 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 ZIP <br /> CA 96019 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[:] FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDCMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent'or Responsible Parry and I acknowledge that all PERAHTFEES, <br /> PENALTIES,EA'FORCEDfEA'T CHARGES and/or HOURLY CHARGES associated With this project Will be billed to me at the address identified above as the ACCOUNTADDRESS for(his site. I also certify that all <br /> information provided on this application is true and correc(;and that Al 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 Owner,Operator,Authorized Agen4 or Responsible 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 HEALTH DEPARTMENT <br /> 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) David L. Kirk for Lawrence & Assoc. SIGNATURE >-•s'.�L'7I- <br /> TITLE Vice President TAX ID# <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPERECEIPT# CHECK 11 RECEIVED BY WORK PLAN PE <br /> FEE: �_. / l0 <br />