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'2FRCM, FAX NO. :2099315186 ' '3 09 2003 04:14PM P13 <br /> Page 6 <br /> State of Cabfcrnia <br /> PRg1`Z=0W AGENCY R4ozW Water Quality Control Board <br /> APPLICATION/REPORT OF WASTE OISCHARGE ,� + <br /> GENERAL:INFORMATION FORM FOR Ya a <br /> WASTE DISCHARGE REQUIREMENTS OR NPOES PERMIT <br /> A. Facility: I. PACILITY INFOMMTION <br /> NILMe, <br /> t <br /> G�1�nartc� crus( �ood�o �L. <br /> "ftaoat /Ball a R <br /> eYtrr �.� < �co`%n�tr <br /> ,/x.7171/1 rJ'�//�/ `//y�r..��Ii�^�// <br /> CaaCaoF PeeroAt <br /> �r—A <br /> Ie, A..- � Tel.p}tan.lFVfnbeee 2 ? i 31—S <br /> D. FacilityOwner: r+ <br /> owner Type (Check onal <br /> rE 2.9 Sadivi&4 3. p c'o�posxCion <br /> 0 GovernmaftEel d,, p Prrtnerahip <br /> Aganey <br /> ClEyr �� _I �t11t•i __d g,1p 03daI Ll <br /> �I r I V L/', 1 QI f4 • T.7.■yhone (lnul,m o P.44re1 Tex=o <br /> C. Facility Operator('The agency or business,not the person): <br /> Nato■t Operator Type (CbGck On <br /> r•r�!N./ �.+41�i V �C. 1. LI zM1vi&14 i.X <br /> cagpWetitm <br /> e■t <br /> nder. ❑ <br /> 3•. dovarrmrerrt■i 4. © peartaerehlp <br /> Cigre i f �� A4eaey . <br /> {/..''Ei elasr y codr■�� <br /> ../'+d1 G�j/����/� +� F.� `+• Q Ther i <br /> C4hEeet PaX■oni1 d l �•1'.f l u�iA� � Tal.—epEc,a L�� � <br /> D. Owner of the Land: <br /> 7►V� 417 <br /> Nam,/ R1nn Type (Check Qne) <br /> sit �►`V 1' a}klividuwL 2. Q CarporrCl.OR <br /> Addsaaar , CvOYIc�1d L'l" 11 <br /> 3. © aovarnm.nee>, i. [� nerfiferaki>,p <br /> y Agency <br /> roate6tP.rangt���I� � Talaphvn.ZnumbaFf • . <br /> E. .A•ddress'Whr..e{�reL,egal Not/ice May Be Served: <br /> 0 <br /> Addt.aar /''•1 Vr IV r i t L "! <br /> CitYt 5 l y/ V 6lllat Cods 75 iZi.T— <br /> Contact$eYsone /" Talephon4 Neanber+ <br /> F. B1111n Address-, <br /> [J t Sip Coder ftl <br /> tapnt■ac peraomt <br /> u� <br /> tornr Ice 1+/f7f �� . <br />