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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOREND Use ONLY OWNERID# CASE It UNIT IV <br /> OWNER FILE:COMPLETE PROPERTYOWNER/RESPONSIBLE PARTY INFORMATION: cNecRIFOwNenis CuRREwLywriLEWIrHEHDEl <br /> PROPERTY OWNER NAME Constellation Brands (209) 365-8188 <br /> FRsT MI LAST PHONE NUMBER <br /> EBS <br /> BUSINESS NAME Constellation Brands USA dba Woodbridge Winery EMAEAO andrea.staoos@cbrands.com <br /> DWNERHOMEADoRES3 N/A <br /> CITY STATE AP <br /> OWNERMAIUNGADURESS 5950 E.Woodbridge Road (c/o Jim Crandall) <br /> MAIU,Nu ADDRESS CITY ACampo STATE CA ZIP 95520 <br /> CJ CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INv# AccouNilD PRWRO# 'ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWOCB_OTSC_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 ❑ <br /> Buti NESSIFACILITY/SUE/PROJECT NAME Woodbridge Winery <br /> SnEADDRES3/PRWECTLOCATION 5950 E.Woodbridge Road SUITE# BUSINESS PHONE <br /> 209 365-8188 <br /> CmAcampo sT"TE CA aP 95520 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPT KEY2 <br /> MAILING ADDRESS,IF DIFFERENT mom FACILITY ADDRESS ATTENTION:ORCARE OF(OPTRMML) Jim Crandell <br /> MAILING ADDRESS CITY STATE IJP <br /> SIC CODE APN# COMMENT: - <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF(OPWML) <br /> MAIUNGADDRESS PHONE <br /> Cm ,y, STATE CA IJP 95206 <br /> ACCOUNT ADDRESS TO SEN O FEES AND CHARGES: OWNERQ FACILITY/BUSINESSM THIRD PARTY BILLINGD <br /> BILLING AND COMP L CE AC"OWLEDGMENT: I,the ondernigaed AppkA.I,certify that l am the Owner,Operatur,Au#mriZedAgeRY,or Responsible Perryend lacknowledge lbat all PERMITFEES, <br /> PENSLTTEB,ENFORCEAY£NT CILIFGESand/or Hoval,CNMG£S associated with this project wil be baled to me at the address identified above As We ACCO17NTA00%SS for this do, I260 ratify that eD <br /> informodon provided on tibia application is nue and correct;and that all regdafed.cavities will be performed b accordance wild all appDrable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL laws and REGULATIONS. As the eadersigned Owner,Operalar,AulharizedAgen4 ar Rmpamthis Party for the project bated above under Gciliry/sire address.l <br /> hereby aetherne the release or any and all results,repor6,and other environmental assessment information t0 SAN JOAQUW COUNTY ENVIRONMENTAL HEALTH DEPARTMENT n Soon a it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT)JIM Crandell SIGNATURE <br /> TEE Facilities Director TAXID# <br /> APPROVED GY GATE ACCOUNNNOOPFCEFROOE9SNO COMPLETED BY DRE <br /> SREMIDGATJON AMOUNT PAID DATEOFPAYMENT PAYMENTTYPE RECEIPT# CHELN# RECEIVED BY WORN PLAN PE <br /> FEE: <br />