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Page 5 CALIFORNIA ENVIRONMENTAL State of California socnc�s PROTECTION AGENCY Regional Water Quality Control Board `¢ f APPLICATION/REPORT WASTE DISCHARGE m GENERAL INFORMATION FORM FOR � s' WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT �LlIORKs'. I� :A. Facility: I. FACILITY INFORMATION 4 Name: French Camp RV Park and Golf Course Address: 3919 E. French Camp Rd City; County: State: Zdp code: 1 Manteca San Joaquin CA 95336 I Coatact Pernon: Telephone Number: Jack Verderame (209)234-3001 B. Facility Owner: Name: Owner Type (Check one) I Canada Cove,LLP 1'❑ Individual 2 ❑ C.ip°rat,on iAddress: 3.❑ Governmental 4. ❑✓ P rtner hip _ P.O. Box 1500 Agency r - City: state: Zip code: I Other: French Camp CA 95231 Contact Person: - Telephone Number: Federal Tax ID: E Jack Verderame (209)234.3001 94-2706173 C. Facility Operator(The agency or business,not the person): Naga: Operator Type (Check one) Crporation Canada Cove, LLP ' ❑ T a;`nd+tal 2 ❑ Address: Paftne.ship � 3.� Governmental 4. ❑ P.O. Box 1500 Agency City: State: Zip Coda: French Camp CA 95231 s. ContactPerson: Telephone Number; Jack Verderame (209)234-3001 D. Owner of the,Land: f Name: Type (Check one) Canada Cove,LLP 3- El xndi a- z ❑ corp—t:s— { Address: - 3 Grnrerrmental 4- Pactaerehip P.O. Box 1500 Agency City: state: Zip Cade: French Camp CA 95231 s- ❑ °�''� 1 Contact Person: Telephone Number: Jack Verderame (209)234-3001 { E. Address Where Legal Notice May Be Served: { Address: . 3919 E. French Camp Rd. City: state: zip code: Manteca CA 95336 Contact Person: Tel hone Number: Jack Verderame 20 234-3009 1 F. Billin Address: Address: P.O. Box 1500 City: Slats: Zip Code: t French Camp ; CA 95231 Contact Person: Telephone Number: - f Jack Verderame (209)234-3001 eo�m zooisis��