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r <br /> DATE San *quin County Environmental Health Department <br /> _ _ MFR <br /> MASTER FILE RECORD INFORMATION Al rr GREEN FORM <br /> _ <br /> OWNERID# <br /> CASE# UNIT IV <br /> GbMPLE7E7HEFOuofamfGPRO PERTY OWNER INFORMA>ro,- FILE <br /> 'ROPERTYOWNERNAME OVIF OWNER CORRERH.rORETL£WETEf END ❑ <br /> Fist PRUNE <br /> Mt as( <br /> N,SINES$NAME <br /> Woodbrid a Winer b Robert Mondavi SOCSEC/T"rD# <br /> Avner Home Address <br /> 5950 East Woodbridge Rd. Dtuver's LTcE„SE# <br /> Qry <br /> Acampo, CA <br /> Avner Mailing Address <br /> "*E uP95258 <br /> PO Box 1260 <br /> Nailing Address City <br /> Woodbridge <br /> T^="= .'- - StateCA 7095258 <br /> CORPORATION <br /> INDIVIDUAL❑ <br /> PARTNERSHIPO FEDAGENCy❑ <br /> orNER❑ <br /> FACILITY FILE <br /> faaury ID# / ! CRO55 REF ID# <br /> ACCOUNTID# <br /> OMPLETE 7HEFOLLOWING <br /> �aaa�,yj- INV# <br /> iously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br /> k this a NEW Business LocgrroN not prev <br /> k this an EXISTING Business LGrATIGN but a NEN/TYPE Of regulated BuslnessYEs 117 No 12 <br /> BUSINESS/FACILRy/SITE NAME YER NO ❑ Unk. <br /> STEADDRFSS WOOdh e iner b7 Robert Mondavi <br /> 5950 East Woodbridge Rd. Surns# BUSINESS 509i369- <br /> aT 866 <br /> Acampo, <br /> Sr"TE CA z"'95258'. BOARDOFSUPERVISOR DISTRICT <br /> LOCATION CODE KEri <br /> KEy2.. <br /> Mailing Address'fo"FERENT/rom F.ci/ilyAddress <br /> Attention:or Care of(option./) <br /> Mailing Address City i <br /> Woodbridge CA STATE ZIP 95258 <br /> SIC CODE APN# <br /> -0oMMENr: <br /> THIRD <br /> BUSINESS <br /> PARTY BILLING INFO; Comp/eteif Billing party /s different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME <br /> LennedyjJenks Consultants Attention:or Caro Of (optloyt) <br /> Mailing Address <br /> 622 Folsom StMike McLeod _ _ <br /> . PHONE <br /> t]Iy 415-243-2150 <br /> San Francisco <br /> �"'� CA zip 94107 <br /> '102IM'A^^ -forfees and charges <br /> OVVf1PR FACILITY/BUSINESS <br /> Aauvc evn t' A _ THIRD PARTY BILLING <br /> PENALTIES,FN-R 1,the udenigced Applicant,certify that I mn dIe Owaer,Opemfar,or Aurho <br /> coded on this ap antVor HOURLYCRAR4Ef associated with Ntis o rged Agent of this Business,and I aclumwle <br /> all information provided on this application is true and corral;and that all regulat dtndiv tie he <br /> billed <br /> perfonned�in a cordance witdd,".identiflOh all o al ala, OC JOA4 DD �e that all PIXn,rEy ti"t <br /> SWndaMs and STAre amyor FEDERAL Lvws and Regulatianc Astheundem P u,ar far this sit¢. Ialso certify that <br /> Ordhoolea Call. ad/., <br /> any and all results and enviranmental assessment infmnmtion to SAN JOA�nd owner,operator,or agent of the ro located Rt the above facility/site a dress,I h=by authorae tile r,l ase of <br /> provided to me or my rein Sa btive. QUIN'COUNTY ENVIRONAIFN FAL HEALTH DHPARTAIIM e,soon as it is Available and at the some time it u <br /> APPI ICANT NAME,Ir PLEASE PRINT <br /> M Leod SIGNgiURE <br /> TITLE <br /> Geologist <br /> DRIVER'SLTCENSE# [ <br /> (PNOTOOD"REQUI ED) <br /> APP d 8y n <br /> ate 2902-002 Ap 125 2003 _ 9 Cam let d By I D t <br /> - - 3/3o/n5 <br />