Laserfiche WebLink
Apr. 29. 2009 2: 29PM LA'" ';FICES OF W. RUSSELL FIELDS No, 3135 P. 2 <br /> Pagea <br /> CALIFORNIA ENVIRONMENTAL State of California <br /> PROTECTION AGENCY Regional Water Quality Control Board <br /> APPLICATION/REPORT OF WASTE DISCHARGE <br /> GENERAL INFORMATION FORM FOR r <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT o �* <br /> A. Facility: <br /> =• PACILITY INFORMRTION <br /> mama: <br /> Fields Family Vineyard and Winery <br /> Addroao: <br /> 3819 E. Woodbridge Road <br /> City: County: stets: Zip Cods <br /> Acampo San Joaquin CA 95220 <br /> Contact Pereom Telephone Nuubar: <br /> Russ Fields 209 482 0427 <br /> B. Facility Owner: <br /> Name; Type (Check Ona) <br /> Russ Fields 1• L✓1 mna ' z. ❑ carp°�ati°n <br /> Addy*e*: <br /> 3. Governmental d. ➢amurehip <br /> 3807 E.Woodbridge Road Agoncy <br /> 7- code <br /> City: State: Zip : b. Other: <br /> Acampo CA 95220 <br /> contaot Person: Telsph=*N=beri ruderal Tax ID: <br /> Russ Fields 209 482 0427 550-75-6040 <br /> C. Facility Operator(The agency or business,not the person): <br /> Name: Cp*ratior Type (Check Ona) <br /> Fields Family Vineyard and Winery 1• Xci&vidma 2• ❑ Corporation <br /> Address: 3. Gov*rnmental d. ❑ whip <br /> 3819 E,Woodbrid a Road Agency + <br /> City: state: Zip COO*: <br /> Acampo CA 95220 5, Other: <br /> Contact Nreon: Telephone Nom: <br /> Russ Fields 209 482 0427 <br /> D. Owner of the Land: <br /> Name: Tyypo (ch*ok On*) <br /> Russ Fields 1L/ xdividral 2. ❑ Ccz7oration <br /> Addrees: 3. t3ov*rnmentel 4, Dartnarahip <br /> 3807 E.Woodbridge Road Agenoy <br /> City: St*ta, Zip Code: <br /> Acampo CA 95615 s. Other: <br /> Contact Fergon: Te1c®h=e Nuxbar: <br /> Russ Fields 209 482 0427 <br /> E. Address Where Legal Notice May Be Served: <br /> Address: <br /> 1792 Tribute Road#400 <br /> City: Stela: app Code: <br /> CgSR�acragm�.eantto CA 95815U83 KIN M9 <br /> 7 <br /> or. <br /> F Billing Address: <br /> Addreca: <br /> 3807 E.Woodbridge Road <br /> City: stator zig Code: <br /> Acampo CA 95220 <br /> Contact Fargo": Telephone,Mzbar: <br /> Russ Fields 209 482 0427 <br /> Form 200(8/97) <br />