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4 � San Joaquin Valley Air Pollution Control District HEALTHY Indirect Source Review (ISR) - Air Impact Assessment (AIA) AIR - z Residential/Non-Residential/Mixed-Use Application Form LIVING" A. Applicant Information Applicant/Business Name: Ft� (AM 9k7V f+L \�w Aoi Mailing Address: �Ssoc �) �u( City: State: ( Zip: Contact: Pkt T- Title: Ott • f4e Is the Applicant a licensed state contractor? No ❑Yes,please provide State License number: Phone: LGgAe I. Z151F, 0 1 Fax: Email:-71 UJA yll S U fV e Gi PM�b ' COM B. Agent Information (if applicable): tt'an Agent is signing the Air Impact Assessment Application on behalf ofthe Applicant,a signed letter ITom the Applicant giving the Agent authorization is required. Agent/Business Name: Mailing Address: City: State: Zip: Contact: Title: Phone: Fax: Email: C. Project Information Project Name: C-aKt A Q0 C�A{_ C WG, Tract Number(s)(if known): Project Location Street: G .Q 1� �- = ( City: SSV-roo Zip:q-511,15- Cross Streets: c ci✓IX.i County: Permitting Agency: SkR r�-_Vt- ° Planner: Mailing Address: ��E� �� FCity: Sj-pCkl . State: C_�, Zip:7'5L1@!5 Permit Type and Number(if known): Subject to Project-Level Discretionary Approval? O Yes ❑No Last Project-Level Discretionary Approval Date: Last Project-Level Ministerial Approval Date: D. Project Description Please briefly describe the project(e.g.:300 multi family residential units apartments and 35,000 square feet of commercial uses): �19D 4 C.*t0,Mt Tuuo IIAN "Roll © Y)WI lL. X3v �t Please check the box next to each applicable land use below: Select land use setting below: Commercial/Retail ❑ Educational ❑Office ❑Warehouse �Z Urban ❑ Rural Residential ❑ Government ❑Industrial ❑Distribution Center ❑ Recreational(e.g.park) ❑ Medical ❑Manufacturing ❑Other: E. Notice of Violation F. Voluntary Emission Reduction Agreement Is this application being submitted as a result of receiving a Is this project part of a 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# G. Optional Section, Do you want to receive information about the Healthy Air Living Business Partners Program? ❑Yes . No FOR APCD USE ONLY Filing Fee s0Ak' oD Check Date1911 Date Stamp: Permit Received: Q-zu- 7�n #: J,,e r I`l� Date Paid: G• Lle ' ZO �a Project SEP 2 6 2019 Applicant#:- C`�O-J) q5 #: u Zo 4G 0 44 SJVAf'Cb Central Region Office: 1990 E.Gettysburg Ave.Fresno,CA 93726-0244 TEL(559)230-6000 FAX(559)230-6061 WEB www.vallevair.orq Page 1 of 12 Residential/Non-Residential/Mixed-Use Application Form Revised June 28,2019