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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> - — N <br /> SH END USE ONLY OWNER ID# CASE# 5Qp(� �� UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNEcavCwaeau CuaaeNrcroN Fa£wirN EHD � <br /> PROPERTY OWNER NAME Constellation Brands (209) 365-8188 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINmeNAIM: Constellation Brands USA dba Woodbridge Winery �ILADOandrea staoas@cbrands.com <br /> OWNERHOMEADDREBS NIA <br /> CITY STATE ZJP <br /> OWNER MAILING ADDRESS 5950 E.Woodbridge Road (cJo Jim Crandall) <br /> MAIuw ADDRESS CITY ACampo STATE CA Iu 95520 <br /> LY CORPORATION ❑INDIVMUAL D PARTNERSHIP D GOVERNMENT AGENCY ❑RESPONSIBLE PARTY D OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENTW RY LIANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY,IO#°` INV# ACCOVNTI PR#!RO i SSIGNED EMPLOYEE LEAD AGENCY EHD_RWQCB_y DTSC EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No D <br /> BU$INESBIFAGUT,/SRE/PROJECTNAME Woodbridge Winery <br /> SREADDREBSIPROJECTLOCATION 5950 E.Woodbridge Road SUITE# BUSINESS PHONE <br /> 209 365-8188 <br /> Cm STATE CA 'P 95520 <br /> Acla'mpo <br /> BOAROOFSUPERVISORDISTRICT O� LOCATION CODE Q {a KEYT <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTEwriowoRCAREOF(OPTIONAL/ Jim Crandell <br /> MAILING ADDRESS CITY STATE zP <br /> SICCODE- APN# COMMENT: <br /> /70- ocry ' <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTEanON:ORCARE OF(OPT)ONAL/ <br /> MAILING ADDRESS PHONE <br /> Cm STATE CA LP 95206 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERO FACILnY/BUSINESS['],y THIRD PARTY BILLINGO <br /> AND C L NCE ACIDiQW l GMENT: 1.the undersigned Applicant certify that I am the Owner,Operator,AulholiLedAgenl,or Rerpowth/e Party and 1 acknowledge that all PE2UHFEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES asseninted with this projeet will be billed to we at the address identified above as d.ACCOUNTADDREST for this site. 1 also certify that all <br /> Information provided on this application is hne and cerrecU and that all regulated activiter will be perfornsed in amordance with all appNcable SAN JOAQUIN COUNTY ORDMANa CODES andlor <br /> STANDARDS aM STATE and/or FEDERAL Laws RM REGULATIONS. As Me undersigned Oona,Operanr,AalhorrzedAgen(ar Rapnnrible Parry for tR project basted above under faciNly/Silt addre I <br /> hereby auNorire the release of any and all results,reports,and other envirunnennl assessment inforalaten in SAN JOAQUIN COUS Y ENVIRONMENTAL HEALTH DEPARTMENT as Senn an it 6 available <br /> aM at the same fine it is provided to me or any representative. <br /> APPLICANT NAME(PLEASE PRINT)Jim Crandall <br /> SIGNATURE <br /> TITLE Facilities Director TMID# <br /> APPROVEDDY DATE ACCOUNrINO OFFICE PROCESSING COMPLETED BY DATE <br /> SDEMITIGA ION AMOUNT PAID DATEOF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WHPIAN PE <br /> FEE:$ 2) 11.. Olt/O J/ <br />