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X19 7_J IT <br /> San Joaquin Valley Air Pollution Control District HEALTHY <br /> �)M Indirect Source Review (ISR) - Air Impact Assessment (AIA) AIR <br /> q <br /> Residential/Non-Residential/Mixed-Use Application Form LIVING <br /> A. Applicant Information t� <br /> Applieant,'Business Name: J RTINDW M61 i I <br /> Mailing Address: 3412.5 Tf�`I-ok PtveNUE City: tt JVV Rip State: CA, Zip�� <br /> contact: 3'itie: <br /> Is the Applicant a licensed state contractor? ®No ❑Yes,please provide State License number: <br /> Phone:( (D)-2 00 t,`i p am a 4I e 0mcA 1w`Gi7m <br /> E. Agent Information (if applicable): trap Auc,a is„sy;ing tha kir Impact Applic'nion on tchalf'of0ic Applic.,1111.., <br /> m,ned ldtcr Ironi Lhe AppIicant gkin!!thr Agum:mm(If i;a14)U i,rutuu [. <br /> AgentlBusiness Name. <br /> Mailing Address: City: State: Zip: <br /> Contact; Title: <br /> _.._. .........._ ._��......... _ <br /> Phone: Fax: Tamil; <br /> C. Project Information <br /> Project Name: PA ^ )A 00-1,k)3 (CA) �" iC���� � � 7 tact Nunaber(s)(if ktao�vit) <br /> ._. <br /> Project Location 1 Street: 2A40 "WIS ROAD city: Zip:g5205 <br /> Cross Streets: MAR p OS R 901%rD County:SA N J OAOIM N <br /> Permitting Agency: Planner: <br /> Mailing Address:'Zg1,W3 INW(Z ft�WA Citv: HmN tib State: (A j Zip:"L?4� <br /> Permit Type and Number(if known): Subject to Project-Level Discretionary Approval? ❑Yes ❑No <br /> Last Project-Level Discretionary Approval Date: <br /> Last Project-Level Ministerial Approval Date: <br /> D. Project Description <br /> Please briefly describe 1he:prcject(e.g..300 multi family residential units apartments and 35,000 square feet of commercial uses): <br /> °arta p►tASE GIM APPROVAL ft*- W\ACA-+'TP-AI LSIO, F^RY.tt & <br /> - _ ...... <br /> Please check the box next to each applicable land use below. Select land use setting below: <br /> ❑ Commercial/Retail ❑ Educational ❑Office ❑Warehouse <br /> ❑ Residential ❑ Coverm ent Industrial ❑Distribution Center Urban (� Rural <br /> ❑ Recreational(e.g.park) M dlcal Manufacturbi— ❑falter. <br /> E: Notice of Violation F. Voluntary misslon Reduction Agreement: <br /> 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 <br /> Notice of Violation(NOV)from the District? Emission Reduction Agreement(VERA)with the District? <br /> No ❑ Yes,NOV# No ❑ Yes, VERA 4 <br /> G. Optional Section <br /> Do you want to receive information abort the Healthy Air Living Business Partners Program? ❑Yes ® No <br /> FOR APCD USE ONLY <br /> Filing Fee Check Date Stamp; Finance Da% ? I rNi ,Wfflt <br /> Received: #: _. I1t�, AIR�IR 1 7 ?020 <br /> Date Paid: Project <br /> p�litrtt :G3 .q #:_ >f 'art i �s �Ae <br /> Central Region Cffice: 1990 E.Gettysburg Ave,Fresno,CA 93726-0244 TEL(559)230-6000 FAX(559)230-6061 WEB vo,-.,rt,yatta air r:.0 <br /> Page 1 of 12 Residential/Non-Residential/Mixed-Use Application Fort Revised June 28,2019 <br />