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. . ,-- -I , i �,4=TIVW_Kvg, g- ? <br /> g <br /> �Ojj <br /> FORM <br /> DATE I I Z % O d MASTER FILE RECORD INFORMATION <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: cHccxx OWNER CUimfFNriycerj,zwTNEHD El <br /> .............................................................................................. ..................................... ...................................................................................................... <br /> PHONE <br /> BUSINESS <br /> OWNER NAME --------------------- <br /> ................................I........................az.................................... ...................................... .................................... <br /> BUSINESS NAME(d driffarent from Ourner Name) SocSr;c/Tu[Dg <br /> WILD ROSE VINEYARDS <br /> OWNER HOME ADDRESS 1294 COLETTE STREET DRIVER'S LICENSE III <br /> STATE <br /> Cky CA 95242- <br /> LODI <br /> OWNERM,UUHGAOoREq3 (jf0jFF8flEN7*fmmOMoi&rAdar ) i Attention:or Care of (op6onjil) <br /> MR. ROBERT LAWSON <br /> Mailing Address City State i 7;p <br /> CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCALAGENCY12 COUNTYAIXNC Cl STATE AGENCYO FED AGENCY 0 OTHER 0 <br /> FACILITY FILE <br /> FW 7714 W�L,,4 77E <br /> Wf Cut Palma <br /> ."g-M <br /> COMPLETE THE Fat LOWING BUSINESS I FACILITY SITE INFORMATION; YES NO <br /> is thisaNEW s,,;n,,,LocATiom notpr,,,io,%iy regulated by the ENVIRONMENTAL HEALTH DIvI51ON? <br /> 0 <br /> Isthis er,E)USTING Suminess LOCATION but a NEW TYPE Of regulated Business7 yes No <br /> 0 <br /> SusINESSIFACILITYISITE NAME <br /> WILD ROSE VINEYARDS <br /> SITE ADDRESS SUITE it BUSINESS PHONE <br /> 8751 EAST HIGHWAY 12 <br /> CITY STATE zip <br /> VICTOR CA 95253 <br /> "'g <br /> Mailing Address jfD1F9ER&VTftmFw4(ityAddress i Attention:or Care Of(Op6owt) <br /> MR. ROBERT LAWSON <br /> Mailing Address City STATE zip <br /> rare75 <br /> kg <br /> iv MA <br /> g2;g <br /> Ml � <br /> �3 I q . g <br /> T'NIRD PARTY BILLING INFORMATIION; Complete if Billing Party is differentfrom Business Owner Identified above. <br /> ...................................... .............................................­­........................................ ................................. ....................................................................................................... <br /> BUSINESS NAME N <br /> Attention:orCaro Of (0076ons, <br /> GEOMATRIX CONSULTANTS, INC. MR. PAUL DE H <br /> Mailing Address PHONE <br /> 2444 MAIN STREET, SUITE 215 <br /> 559-264-2535 <br /> FRESNO STATE CA Sar 93721 <br /> ACCQLK .AA_DRPss for fees and charges OWNER FACiuTylBUSINESS THIRD PARTY BIILNG <br /> eeeeeeeeee <br /> 1,the undersigned Applicant,cortirycb,I am the owner,opcewor,or.4wh&rizcdA7e'woTTffe.-Busin�m and r 2clmowjcdgc that as <br /> PekVir FrZ.T. PV4UTX& &VMRCZA1r,1T CRUZGZS and/or hiouRzy Ciraem associated with ibis uperstion will be billed to me at the address identified above U the /FT-7 <br /> ADDRETS for this site. t 3130 ccn;I`)r that all information provided on this application is Ime and correct; and that A rcgulAlad activities 'ill be perfbmcd in accordance with all <br /> applicable SANJOAQUE4 COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Lxwx and Regulations. As the undersigned owner,operator,or agent of the prirpeny <br /> located at the jbo•e racilltylsk. address. I h.ntby authorize the relesso or any and all results, and creironmealad ass,ismen, information to SAN JOAQU3N COUNTY <br /> Ej,qVU;iONMENTAL HEALTH DMSION as loon ask is&,aA&blc and at the same time it is Provided to in$Of P nMCIV <br /> PLEASE PRINT <br /> APPLICANT NAME SIG <br /> DRIVER'S LICENSE 0 <br /> TITLE ,.V— _j2.dQjQQQELREQUaEl%L I <br /> ,% sm <br /> g IENEN-�R RIME�F=0%4= <br />