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State of California-California Environmental Protection Agency Department of Toxic Substances Control <br /> TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST <br /> SECTION I: FACILITY INFORMATION <br /> Instructions:Complete the following descriptive information about your facility. This information accurately describes the location of your facility <br /> and establishes mailing and phone contacts. If facility location and mailing address are identical,you may put"same"into facility mailing address <br /> spaces. <br /> Type of Permit: Permit by Rule Conditional Authorization <br /> 1. CURRENT FACILITY NAME: <br /> PAST NAMES(Attach additional pages if necessary): <br /> 2. EPA I.D.NUMBER: CAR0007-9 Z t l 1 <br /> 3. NAME OF FACILITY OWNER(see definition of mvuer): IDrC pyl e A 4e;f/V,-YS <br /> 4. NAME OF FACILITY OPERATOR: GOA-77ni 1D/3 R rc t` ✓ FN NI'ti'a` <br /> 5. NAME OF PROPERTY OWNER: Pre VA t e ( toe+Z f /x/ -✓S <br /> 6. FACILITY LOCATION ADDRESS: <br /> STREET: 7 9 1 0 `e 7 7 7 0 <br /> CITY: , T-P C le, to n1 C - <br /> COUNTY: S f e <br /> STATE: C.t. ZIP CODE: <br /> 7. FACILITY MAILING ADDRESS(if different from FACILITY LOCATION ADDRESS): <br /> STREET: <br /> CITY: <br /> STATE: ZIP CODE: <br /> 8. FACILITY TELEPHONE NUMBER: o`�0 f 9 g Z - SS tY3� <br /> 9. FACILITY FAX NUMBER: 2 -7 9 8,j 410 S c) <br /> W. NAME OF FACILITY CONTACT PERSON: CYGU 1,VA f e S yObk VV <br /> 11. TITLE OF FACILITY CONTACT PERSON: Pre 3/ c-(.1 � r `Civ V t r�• ` SA 1`0 t y <br /> 12. PHONE NUMBER OF FACILITY CONTACT PERSON: <br /> DTSC 1151(06199) please indicate total number of pages ( of <br />