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RD E C <br /> L L Lii_ <br /> San Joaquin County Environmental Health Departme�� ;� Fa <br /> J7FORM <br /> DATEE:::: MASTER FILE RECORD INFORMATION MFR �VUIRUNiVI ( HEnL(I" " <br /> R # CASE#` R1i11T :jjNIT, <br /> IV <br /> FANIDCw ac Hl <br /> OWNER FILE <br /> Cl+etKrF OWNER CuRRENrzronraetvmt EHD ❑ <br /> COMPLETETNEFOLLOWING PROPERTY OWNER INFORMATION; <br /> PROPERTY OWNER NAME Woodbridge Sanitary District PHONE (209)368-0900 <br /> First Ml Last <br /> BUSINESS NAME Woodbridge Sanitary District SOC SEC/TAH ID# <br /> Owner Home Address Woodbridge Sanitary District DRIVER'S LICENSE# <br /> city Woodbridge STATE CA ZIP 95258 <br /> Owner Mailing Address 19720 North Benedict Drive <br /> Mailing Address City Woodbridge State CA ZiP 95258 <br /> TVPF AF AWNFRCMtP <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> /` n\�I�` Q^ - CROSS<REF ID:# t rX� :. ACCOUNT ID'# INV# <br /> FACILITY ID# f Do D c( �J�o U q T��\ O J!-`O <br /> "ti � <br /> OMPLETE rHE FOLLOWING BUSINESS I FACILITY SITE NFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FAcmrry/SITE NAME Woodbridge Sanitary District <br /> SITE ADDRESS 19720 North Benedict Drive SUITE# BUSINESS pHON1209)368-090 <br /> STATE CA ZTP 95258 <br /> CITY Woodbridge <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keri. ICEY2°- <br /> Mailing Address ifDIFFEREA?from FadlifyAddress Attention:or Care Of(opdo—aai) <br /> STATE ZIP <br /> Mailing Address City <br /> SIC.CODE' APN# COMMENT, <br /> THIRD PARTY BILLING INFO Complete if Billing Party is diferentfmm Property Owner or Facility Operator idendfied above. <br /> Attention:or Care Of Copdonal) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> d=QUAT Q=E9a for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn 1 INC `VD C omP I•NC ACxyOw EDG29ENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized.-hent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or 110URLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that <br /> 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 <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PLEASE PRINT <br /> SIGNATURE <br /> APPLICANT NAME <br /> TITLE n v� DRIVER'S LICEN # <br /> (PHOTOCOPY REOUIRED) <br /> Approved By "'111 t Date Accounting Office Processing Completed By Date <br /> 1 <br /> 29-02-002 April 25,2003 <br />