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San Join County,Environmental Health Do tment <br /> 11 GREENFORM <br /> DATESLS. /() 11 MASTER FILE RECORD INFORMATION "MFRf° <br /> SHADED AREAS FOR END USE ONLY OWNER IDM CASE II UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NG PROPERTY OWNER/NFORMAT/ON.' � CHecR IV OWNER CuRRENnvoNrxEyrrREHD � <br /> PROPERfYOWNEg NAME � RLt,/n. F Woods 6171 PHONE (209)601-5240 <br /> First MI <br /> Business NAME Woods Dairy (7 C J f Soc Sm/TAZIDM <br /> Owner Home Address 14250 N. DeVries Road kiAY 6 4 L l i ) DRNER'SLICENSE# <br /> city LodiTGT <br /> R n H EALTH STATE CA 'P 95242 <br /> owner Mailing Address 14250 N. DeVries Road FERNIIT(JERVICE� <br /> Mailing Address City Lodi state CA ZIP 95242 <br /> CORPORATION INDIVIDUAL® PARTNERSHIP El FEDAGEHOY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# ,a` fi 3' CROSS REF IDM AOOOUNTIDM ��tb3 b31.2- INV# <br /> COMPLETE THE FOLLOW/NG BUSINESS I FACILITY I SITE/NFoRMAT/ON: U <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPr.? YES N No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO N <br /> Busasess/FACILnYISDENAME Woods Dai <br /> ry <br /> SITE ADDRESS SUITE# BUsINEsSPHONE <br /> 14250 N. DeVries Road <br /> CM Lodi STATE CA ZIP 95242 <br /> BOARB OP SUPERVISOR DISi1uCr LocvonoN CODE KEY1 KEY2 <br /> Mailing Address HDIFFEREAT from FacilityAddret s ARentlon:or CareOf(options/V <br /> Mailing Address City "' STATE LP <br /> SICCODE APN# O/� 7�� Z,6 COMME .. <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owneror Facility Operatoridenb'fied above. <br /> BUssem NAME - Attention:orCare Of foptiona/J <br /> Mailing Address PRONE <br /> CITY STATE ZIP <br /> ArcayATADDRESS forfees and charges OWNER FAriLJTY/BL/SINESS THIRD PARTY BILLING <br /> Bn-IjNG AND COMPLIANCE ACRRORT.Eecorrom 1,the undersigned Applicant,certify(hat I am the Owner,Operatoq or.4uthorized.4gent of this Business,and I acknowledge that all PERrnr FEES, <br /> FEY.1Enzs,E?vrm ,EAT CHuaEd and/or AousUr Cmmiu associated with this operation will be billed to me at the address identified above as the AC OU.NTAnUai S for this site. I also certify that <br /> all iadorreation provided on this application is true and.,lett,and that all regulated acdv7ties will be performed in accordance with ag applicable SAN JOAQUIN COUMV Ordinance Coda and/or <br /> Standard,and Srwre and/or FEUE laws and Regulations. As the undersigned owner,operator,or agent of the property located at the ab facility/site address,I hereby authorize the release of <br /> any sad an resWb and emiro¢memal assessment information to SAN JOAQUUV COUNTY ENVIRONMENTAL HEAL11l DEPART E as soon as it is available and at the same time It is <br /> provided b me or any representative. <br /> APPLICANTNAMEJim Woods <br /> PLEASEPRINr SIGNATURE �- <br /> ,E /J A,y ^ DRIVER'S LICENSE <br /> /9 I< 7/t/ 1 4 (PHOTODOPYREOUIR�ED)�p <br /> Approved By Data Accounllog Oltice Processing ComPleled By Data S ZS (] <br /> 79-02 10/17107 MASTER FILE RECORD-GREEN <br />