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SAN *UIN COUNTY ENVIRONMENTAL HEALTH*ARTMENT DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM $ITE MITIGATION & LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNERS CURRENT[Y ON FILE W/TH EH Diamond Pet Food Processor PROPERTY OWNER NAME f Ripon, LLC ( ) (209)824-4640 FIRST MI LAST PHONE NUMBER BUSINESS NAME Diamond Pet Food Processors E-MAILADDRESS of Ripon, LLC OWNER HOME ADDRESS 942 S. Stockton Ave. CITE' Ripon STATE ZIP CA 95366 OWNER MAILING ADDRESS Same MAILING ADDRESS CITY STATE ZIP ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY X HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# ]LPR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRW —X X DTSC_EPA ACCOUNT ID Jo vfwR�y 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 M No ❑ BUSINESS/FACILITY/SITE/PROJECT NAME Diamond Pet Food Processors of Ripon, LLC SITE ADDRESS/PROJECT LOCATION 942 S. Stockton Ave. SUITE# BUSINESS PHONE CITY Ripon STATE ZIP BOARD OF SUPERVISOR DISTRICT Ll LOCATION CODE O KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OP770NAL) MAIUNG ADDRESS CITY STATE ZIP SIC CODE APN# r h_ COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Lawrence & Assoc. ATTENTION:ORCARE OF (OPTYONAL) MAILING ADDRESS 3590 Iron Court PHONE (530)275-4800 Crtv Shasta Lake STATE ZIP CA 96019 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNO"LEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Party and 1 acknowledge that all PERMIT FEES, PEAALTtES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. 1 also cerfify that all 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 STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Parry for the project located above under facility/site address, hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) David L. Kirk for Lawrence & Assoc. SIGNATURE s� TITLE Vice President TAXID# APPROVED BY DATE ACCOUNTING OFFlCE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEE: ;'U