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• San Jilin County Environmental Health lartment <br /> DATEGREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" J N c 'a <br /> SHADED AREAS Eok EHO USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NG PROPERTY OW N ER/NFORMAT/ON: Cwecvr m OWNER Ctmnwmrwsnewm/EHD <br /> PROPERn oMME1t NAME nt'-/h F Woods &7K PHONE (209)601-5240 <br /> First MI <br /> BIlRNE88 NAME Woods Dairyntutvw In SOCSEC(Tm ID# <br /> Owner Home Address 14250 N. DeVries Road MAY 2 4 LY"l) DRNER'S LICENeE# <br /> city Lodi Eki\jinowaT HEALTH ETA'E CA z" 95242 <br /> OwneirMalling Address 14250 N. DeVries Road PERMIT/SERVICE5 <br /> Mailing Address City Lodi state CA 9P 95242 <br /> CORPORATION❑ INDIVIDUAL® PARTNERSHIP❑ FEDASENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID# CRoss REP ID# ACCOUNT ID# INYff <br /> COMPLETE THE FOLLOW/NG BUSINESS/FACILITY I SITE INFORMATION: <br /> td this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ® NO ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINEss/FAcnrrrSRENAME Woods Dairy <br /> SmADDRESS SUITE# BUSINESSPHONE <br /> 14250 N. DeVries Road <br /> CIT" Lodi STATE CA zip 95242 <br /> BOAROOFSuPERWsORDasnucr LOCATION CODE KM KEY2 <br /> Mailing Addresa NOIFFERENT from Faa/#tyAddresa Attention:or Care Of(op#onal) <br /> Mailing Address City STATE LP <br /> SICCODE APN# ©5! Zry y6 COMMEM: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owneror Facillty Operatoridentfied above. <br /> BuIDNEss NAME Attention:orCam Of(optiana/J <br /> Mailing Address PHONE <br /> C" STATE ZIP <br /> Aforfees and charges OWNER FACILrry/BUSINESS THIRD PARTY BILLING <br /> BfLI.TNa MT COafPL1ARCR ACTa:owLEDCMENr: 1,the undersigned Applicial;certify that I am the Owner,Operator,or.4schorucd.4gcW of this Business,and I acknowledge that all PEzeiar FEES, <br /> PEwH.TtEe,EneroacrnrenTCanRGEs and/or NotstzY CeuceT associated with this operation will be billed to me at the addreu identified above as the AceoyorADDRErs for this site I also certify that <br /> ail hffO m tion provided on this application is time and comet;and that of regulated activities will be performed in accordance with all applicable SAN JoAQuw Coumv Ordinance Codes and/or <br /> Standards and STATE and/or FEDERt.I.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 and of results and eorvonmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARt+ E as soon as N Is available and at the same time it is <br /> provided to me or my representative. �. <br /> APPLICANTNAME PLEASE Pwrrr SIGNATURE Itj <br /> Jim Woods 2 <br /> DRIVER'S LICENSE# <br /> / /12 7Qj /-4 (PHOTOCOPY REQUIRED) <br /> Approved By Data Ann oungotl Office Pro caeaIng Completed By Dab <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />