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Page 5 CALIFORNIA ENVIRONMENTAL State of Calitorrda ¢�gc ces o0 PROTECTION AGENCY Regional Water Qttality Control Board �s+� ., y�� F APPLICATION/REPORT OF WASTE DISCHARGE �o GENERAL INFORMATION FORM 1=0R o� WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT C4lIFCP A. FaCIIItV: I. FACILITY INFORMATION Name: Sutter Home Winery Westside Facility Address.- 18667 ddress:18667 Jacob Brack Road City: Ccun ty: State: Zip Code: Lodi Isan Joaquin 1 95242 Contact Person: Telephone Number: Robert D. Torres 707 963-3104 B. Facility Owner: Name: 'IYPa (Check Check one) . Sutter Home Winery Inc. I- ❑ Individ a, 2. Corporation Addrress: �7 p 3. ElGovernmental4. Partnership P.O. Box 240 Agency City: State: Zip Code: 5. Other: St. Helena CA 94574 Contact Person: Telephone Number: Federal Tax ID: Robert D. Torres (707) 963-310 94-1.080860 C. Facility Operator (The agency or business,not the person): Name: Operator Type (Check One) _ Same as facility L Indiviaval 2. Corporation owne Address: 3. Governmental 4, Partnership Agency City: State: Zip Cade: i S. El Other: I Contact Person: Telephone N=ber: D. Owner of the Land: Name: owner Type (Check One) Same as facility owner L ❑ Individual 2. ® Corporation Address: 3. Governmental 4. ❑ Partnership Agency City: State: Zip Code: 5. ❑ Other: Contact Person: Telephone Numher: E. Address Where Legal Notice May Be Served: Address: P.O. Box 248 City.: State: Zip Code: St. Helena CA 94574 contact Person: Robert D. Torres Telephone Number: 707 963-3104 F. BiliinQ Address: Address: P.O. Box 248 Cit., Sate: Zi Code: St. Helena CA 9+574 Contact Parson: Telephone Number: Robert D. Torres (707) 963-3104 I