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l <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 11/15/2013 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADEDAREAS FOR EHO USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION; CHECK IF OWNERIS CURRENTL YON FILE W?H EHO <br /> PROPERTY OMER N A ME Ryan George 209) 833-53B3 <br /> FIRST MI LAST PHONE/NUM13ER <br /> E-MAILADDRESS <br /> BUSINESS NAME <br /> Prologis, Inc. rgeorge@prelogis.com <br /> OWNER HOME ADDRESS <br /> Business 17264 West Commerce Way <br /> L+m, STATE ZIP <br /> Tracy CA 95377 <br /> OWNER MAILING ADDRESS <br /> MAILING ADDRESS CITY $TATE ZIP <br /> ff CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT?VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_,LOP_ <br /> - -FACILITY-ID# - -- --INV# Acco'uINTID- nn PR#/RO# - AssioNEDEMpIOYEE LEAD-AGENCY:EHD-RWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESS/FACILITYISITEIPROJECT NAME Nestle Direct Store Delivery Company <br /> SITE ADDRESS I PROJECT LOCATION SUITE BUSINESS PHOj'IE <br /> 1351 Dupont Court 209- 24-8343 <br /> Cm STATE CA LP 95336 <br /> Manteca <br /> BOARD OF SUPERVISOR DISTRICT 10(5 1 LOCATION CODE ot� KEY1 KEY2 <br /> MAILING ADDRESS.IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILINOAODRESSCITY STATE ZIP <br /> 11$IC 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 Geosyntec Consultants, Inc. ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILINGAODRESS 3043 Gold Canal Drive, Suite 201 PHONE 916-637-8046 <br /> CITY Rancho Cordova STATE CA zip 95670 <br /> ACOOUNTAODRESs TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILUNGLI <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERMITFEE$ <br /> PENAL77ES,ENFORCEMENT CHARGEE and/or HOURLyCHARGEB associated With this project Will be billed tome at the address identified above as the ACCOUNTADDRESS for this site. 1 also certify thatall <br /> information provided un this application is true and correct;and that all regulated activities will be performed in accordance with Ili applicable SAN.IOAQUIN CO RV ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.As the undersigned Owner,Operator,Authorized Agent,or Responsible Patty for the project beat, v,.under facility/site address,I <br /> hereby authorize the release of any sod all results,reports,and other environmental assessment information to SAN JOAQUIN COU ENVIRONIIE,NT, FALTIi D AR d1FM as soon as if is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Joe Niland (Geosyntec; Agent for Nestle) SI TURF <br /> TITLE Principal TAX'D# 59-235 13 <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMM�ENT TYPTE- RECEIPT# /-/ CHECK# RECEIVED BYT�)094 <br /> KPLAN PE <br /> FEE:$ 3?� �� S I/rl��f Cf�l�1 I lAV �fr�T J O <br />