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San Joaqu . Valley Air Pollution )ntrol District HEALTHY � ,y #, :�indirect Source Review(ISR) -Air Impact Assessment(AIA) �� ResidentiaVNon-Residential/Mixed-Use Application Form LIVING A. Applicant Information Applicant/Business Nanie., Gurdwara Gur Nanak Parkash,Inc.(Deep Singh) Mailing Address: 16101 W Grant Line Road City: Tracy I StatC:CA Zip: 95304 Contact: Deep Singh Title: Secrotmy Is the Applicant a licensed state contractor? N No ❑Yes,please provide State License number: Photic:(702)287-0347 Fax: Email:tony@continentaldc,com;TracyOurdwat'aQhotmuii.com B. Agent information(if applicable);tfan Agent is signing the Ali,Impact Asxcs.;mem Apphetuinn,a,heh;dfnf a,e Applicant.it signed letter front the Appliaml gh ing the;igen uuth„riiation i.rerun-d. Agent/Business Name: Mailing Address: City: State: Zip: Contact: Title: Phone: I`ax: Email: C. Project Information Project Name: GURDWARA GUR NANAK PRAKASti Tract Number(s)(if known): Project Location Street: ld151 W.GRANT LiNEROAD , City: TRACY Zip:95304 Cross Streets: HANSEN ! County:SANJOAQUiN .......... Pcrn,iuing Agency: SAN JOAQUIN COUNTY BLDG.DEPT. Planner;ALISA GOUT ART - ._...------------—..-..._.. -------- - ---------- _ ---- .._._._.... CAUFeRN1A I --. - Mailing Address: 16101 W.GRANT LiNE ROAD City: TRACY State: --v i Gip:95304 Permit Type and Number(if known): i Subject to Project-Level Discretionary Approval'? N Yes ❑No PA-1900127 1 Last Project-Level Discretionary Approval Date: Last Project-Level Ministerial Approval Date: D. Project Description please briefly describe die project(c.g.:300 multi family residential units apartments and 35,000 square feet of commercial uses): t.CONSTRUC'ITON OF 28,965 SQ.FT.MAiN ASSEMBLY HALL ALONG WiTH PARKING LOT&DRAINAGE IMPROVEMENTS 2.CONSTIH CTTON OF PAD FOR FI1T[JRl3 SOCIAL HALL.FUTURE SQGiAL HALL TO BE CONSTRUCTED TN PFiAS' LDNMSEPARATE PEWIT ..- Please check the box next to each applicable land use below: Select land use setting below: ❑ Commercial I Retail ❑ Educational ❑Office ❑Warehouse F-1Residential ❑ Government El Industrial E]Distribution Center ❑ Urban ® Rural ❑ Recreational(e.g.park) ❑ Medical ❑Manufacturing ®Other:PLACE OF WORSHM E. Notice of Violation F. VOIunt=Emission Reduction A reement is this application being submitted as a result of receiving a Is this project part ora larger project for which there is a Voluntary Notice of Violation(NOV)from the District? Emission Reduction Agreement(VERA)with the District? ® No ❑ Yes,NOV// No ❑ Yes,VERA 11 G.Optional Section Do you want to receive information about the 1-icalthy Air Living Business Partners Program? ❑Yes ® No FOR APCD USE ONLY Filing Fee / Check Date Stamp:Finance Date Statnp:Perlttik Received: r' #: Date Paid:1D/2—//I Project Applicant#:07AV3119 #:C"Mllpkti�1 Central Region Office: 1990 E.Gettysburg Ave.Fresno,CA 93726.0244 TEL(559)230-6000 FAX(559)230-6061 WEB WWW.vallevair.org Page 1 of 12 ResidenliallNon•Residential/Mixed-Use Application Form Revised June 20,2019