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Page 5 <br /> CALIFORNIA ENVIRONMENTAL State ofCalifomia <br /> PROTECTION AGENCY Regional Water Quality Control Board <br /> APPLICATION/REPORT OF WASTE DISCHARGE <br /> w �➢ <br /> GENERAL INFORMATION FORM FOR <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT AL, ,P <br /> A. Facility': I. FACILITY INFORMATION <br /> Name: <br /> Z__I_C <br /> Address: S 1 sy �'e-11 �rv'GJ a "e. -. <br /> sta <br /> C�ty: LL)j ( County: c� Zip Code: <br /> Contact Person: Telephone Number: — <br /> 'lies cc S n It4 5 <br /> VGA' <br /> B. Facility Owner: <br /> Name: ��,Jf' /�/ /L� _ <br /> J�. >fli�1` �b` ��� ' Oemer Type (Check One) <br /> (A +J 1 1. Inds,ri�,at 2. Corporation <br /> Address: _:-., -,<.. . n r..�.,•.....�-...,, e n <br /> Delta Packing Co. of Lodi Inc. 8 2 21 <br /> Vendor: State Water Resources Control Board ID: stwat2 <br /> Invoice No. Invoice Date Description P.O. No. VoucherAmt Discount Amt Pay Amount <br /> 07/28/2014 Imagination Wines form 200 �S,AN JOA00RIO ILINTY 00 1,940.00 <br /> ENVIE QNMEN TAL HEALTH DEPARTMENT <br /> 1868E HAZE' ' NVt i:.%CK I UN,CA 95205 <br /> .170 <br /> PROPOSAL APPR( SU"JL''T 10 <br /> California Regional Water I ` <br /> EEL-OW <br /> a- Quality Control Board Re:n,lrks Q�k - t �Zo �k�����ti ���� <br /> Y -- <br /> co11020 Sun Center Drive, #200 - --In�s _(e.�v� _ . fir-c.� <br /> Rancho Cordova, CA 95670ff114--- - -- <br /> Date - - --- - - — - — <br /> Approval extends c), , t that w c• ' is shown and described <br /> hereon and does not . ,rthonze nr approve any umission or <br /> deviation from requirements of state laws or local ordinances. <br /> Check No.: 82211 Check Date: 07/28/2014 Currency: USD Totals: 1,940.00 .00 1,940.00 <br /> e es e e- e •e a e e c e t e• D • •o. <br /> DELTA PACKING COMPANY OF LODI INC. CENTRAL VALLEY 82211 <br /> OPERATING ACCOUNT COMMUNITY BANK 90-3772/1211 <br /> 6021 E. KETTLEMAN LANE Ph 1-800-298-1775 <br /> LODI, CA 95240 PH, 209-334-1023 <br /> Pay One Thousand Nine Hundred Forty Dollars and 00 Cents USD <br /> 17i4T6 CHECK NO. CHECK AMOUNT <br /> 70 THE <br /> 07/28/2014 82211 1,940.00 <br /> , <br /> 0 of RState Water Resources Control Board <br /> 11020 Sun Center Drive#200 <br /> Rancho Cordova CA 95670 <br /> its 06 2 2 1 .11' 1: 1 2 1 13 7 7 26(: 0 1 7 0 10 2 72,II■ <br />