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SAN J*UIN COUNTY ENVIRONMENTAL HEALTH *RTMENT <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 IFOwNERisCuRRENTLYONFnEwirN E H D <br /> Diamond Pet Food Processor <br /> PROPERTY OWNER NAME 0 f Ripon, LLC ( ) (209)824-4640 <br /> FIRST M/ 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 /> EN CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY X HW PIPELINE INVESTIGATION LOP <br /> [!t <br /> ID# INV# ACCOUNTID PRWRO:j ASSIGNED EMPLOYEE LEAD'AGENCY:EHD_RWQCB' DTSC_EPA._,,, <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 Diamond Pet Food Processors <br /> of Ripon, LLC <br /> SITE ADDRESS/PROJECT LOCATION 942 S. Stockton Ave. SUITE# BUSINESS PHONE <br /> CITY Ripon STATE zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEWI KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE zip <br /> SIC 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 Lawrence & Assoc. ATTENTION:ORCARE 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 ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsihle Part,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENTCHARGES:Intl/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the Ac(OUN%'AUURESS for this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will lie performed in accordance With all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws anti REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Revponsihle Parry 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 EN IRONMENTAL H ALTH DEPARTME T 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 r' <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 TYPE RECEIPT# CHECK# RECEIVED BY WORK PLANPE <br /> FEE:$ I ] <br />