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J <br /> r <br /> Page 5 <br /> CALIFORNIA ENVIRONMENTALRcts <br /> PROTECTION AGENCY State O C�ill{Orl ua t°Sw... oqy <br /> Regional Water Quality Control Board ;o <br /> APPLICATION/REPORT OF WASTE DISCHARGE w o o <br /> GENERAL INFORMATION FORM FOR <br /> WASTE'DISCHARGE REQUIREMENTS OR NPDES PERMIT <br /> A. FaClll I. FACILITY INFORMATION <br /> Name: <br /> b <br /> Address: s <br /> %-I Z R Lou. e uer�uc. <br /> City: County: State: Zip Code: <br /> s�a-Lo n SI,�,S APs 9 5 3 2 a <br /> Contact Paxean: Telephone Number: <br /> a S�.. co O a?34 ^ 400(1 <br /> B. Facility Owner: <br /> Name: owner Type (Check One) <br /> 1. ❑ Individual 2. JR Corporation <br /> Address; �3 (� 3. ❑ Governmental 4. ❑ Partnership <br /> ► a 6q cS {"n Q'IC c 0%M vY`,J i- A4enoy <br /> City,: State: zip Cade: 5. ❑ Other: <br /> 0'-% 1 t-P� 9153 tv to <br /> i Contact Person: Telephone Number: Federal Tax ID: <br /> goq-48i-435 &8 - o k 15051-1 <br /> C. Facility Operator(The agency or business,not the person): <br /> Name: C� l� operator Type (Check Onel <br /> C✓( m� +r7�a7 © 'C'`�-� 1. ❑ ledividal 2. D? <br /> Corporation <br /> Address: 3. ❑ Governmental 4. ❑ Partnership <br /> Agency <br /> City,: State: Zip Code: <br /> 5. Other: <br /> Contact Person: Telephone Number: <br /> D. Owner of the Land: <br /> O�� Type (Check One) <br /> Name: 1.1../f �i ,l 2. ❑ Corporation <br /> p� $ Sh,� 1�. C.o��a... IBJ <br /> Address: n • ` 3. ❑ Governmental 4. ❑ Partnership <br /> 1 d b�{ '5 - c 1��' 4 Agency <br /> City: Stag: Zip Code: <br /> ," \Pon I Ca 175 3(,�tp 5. ❑ other: <br /> ontact Person: Telephone <br />' E. Address Where Legal Notice May Be Served: <br /> Address: <br /> City: State: zip Code: <br /> Contact Person: Telephone Number: <br /> F. Billing Address: <br /> Address: <br /> City: State: Zip Code: <br /> Contact Berson: Telephone Number. <br /> Form 2001fif971 <br /> i <br />