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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE November 3, 2016 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />PHONE 209-480-4663 <br />FIRST MI LAST <br />BUSINESS NAME FJJC Investments, Inc. E-MAIL ADDRESS 1 i sthnyjucii @anl nom <br />OWNER HOME ADDRESS PO Box 635 ATTENTION: OR CARE OF (OPTIONAL) Judi van Riet <br />ciry Ripon sun CA ZIP 95366 <br />OWNER MAILING ADDRESS Same as above <br />MAILING ADDRESS CITY STATE ZIP <br />6 CORPORATION 0 INDNIOUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />IN ENVIRONMENTAL FA EHD LOCAL VOLUNTARY 11 RWOCB LEAD- I RWQCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />DTSC LEAD IN FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No XX <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No a <br />BUSINESS/FACILITY/SITE/PROJECT NAME DeBoer Trucking Am 259-35-013 <br />SITE ADDRESS / PROJECT LOCATION 201 W. 5th Street BUSINESS PHONE <br />CITY Ripon STATE CA ZIP 95366 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEn K'2 <br />MAILING MAILING ADDRESS ,W DIFFERENT FROM FACILITY ADDRESS Same as above <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME <br />ATTENTION: ORCARE OF (OPTI(WAL) <br />MAILING ADDRESS <br />PHONE <br />Crry <br />STATE <br /> zip <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERM <br /> <br />FACILITY/BUSINESSO <br /> <br />THIRD PARTY BILLINGEI <br /> <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information <br />provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br />JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br />Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br />release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.4A,„ r <br />Freda Green, Doug Camara, \e' <br />APPLICANT NAME (PLEASE PRINT) SIGNATURE jaek vezn Riet tj fr6cta creit Judi van Riet, Charlotte Wright <br /> <br />TmE Property Owners <br /> <br />Two* <br /> <br />FA #: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: <br />9-3-2015 <br />Site Mitigation MFR 29-