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LP Performance Record ID# PR0514183 <br /> 2021 E Harding Way Program: HW <br /> August 21, 2019 <br /> PHOTO 1: DTSC form 1358 was filled out and faxed to the DTSC while inspector was on site to reactivate State ID: CAL000363944 <br /> PEp�!'ANEN75T ma'b�" •n..c.e <br /> ATE IU NUMBER <br /> �Loti�icin <br /> �� crw:.ti l�N=aulr -.e�.r...yy,,,•.rv,m�liu,.r�lm APP�Ie � � - <br /> .. nrn,�.a rar n new nenru���.n r„o - - <br /> , .en•nownYhMer: A 11 rr' nlU nnmbnewu xr�q,ynw•nrn ep wrebr i'\blr. <br /> r. •Mldl MJ it ron_IArI e•fnar nr6Po�lor Ri:R.n[ur.�ur I�Irf uelnn..moron G.IInLeBe mn•m�r l.�ryerm <br /> --r.l.Iw �L,eNnre�_gT kern wnuy yllbr Urrol h' Maro�W.�.wnwe.iilMi�dUCFir <br /> _ _G0.13`nydrrM tyA n311rbar <br /> xGEB TO AT'SS OR <br /> FOR TI-H-1 <br /> ,.z•runa�n eu<rmnr <br /> r nn uveunna Ino r,wntr�y adn[no;.na�r�wlrlac- r-21--3--a IV-- 4(-- <br /> 1j I:a I nrn�.mrnr�I,nb min In„n,nre, 1 Inrnrr�„ �nn,y <br /> 161(J. lam r¢a:11Ng11hA 1M1isib nnmbcu G •nil[�isane.2y,li emir: A <br /> .' s_la.n cr�mryxie ma wumm�ss name oniy.n Yd Ytlificalbn�nesuaryna�.e o o{rn�r <br /> SIIEl1=anJltyleuyv'I�y Ngnre(Incl�Mu ppgl �:r <br /> a la)Federal Empl y r ib Numner 511a 2ilr cdan <br /> Ihl 1369[A ul F.4c fr.,*nn Fen Acrr urd Nher Cdr <br /> b)I.ahlY fnquimtl llnlrl:QRilerafers ai ra�nlar dlin SrOnp pnr nrNwldnr yflar-j <br /> [a rrtali�nyAdtlre,e; ,� �tfr1+21�tr/Ci W <br /> Stele Co <br /> 1- <br /> ..,�y_ 10.Sile Conrad Persan: Z/ �v� <br /> �ryel Nana lam Nene <br /> Conldcl Person A4dress' -- tJ y7&Mti f •�_ <br /> 5 S� <br /> clrr srAm zlp caae <br /> _ Contac)Pelson Phone Number <br /> A— <br /> S '•` Ar—ea fid¢ Ph�a�her Fwa:Cctla F��Ndm ,�r — <br /> Contact Person Business Email Address. 'L T� <br /> 11. Legal Suslness Owner(nol property owner): zuz <br /> NBmg 'W���f <br /> Owner Address; -QLz2I.-E J ,,C; V Safd -1 A Gjt�u r <br /> street _ City State Tipcod. <br /> Owner Phone Number. 0,7 3S 1• 1 0 JLL Fax Number _) t i• <br /> Area Code Phone Num.er Area Code Fa Number <br /> r .N <br /> 12. Standard Irtduslnal Classtrrafian(SIC)Code for the Sile: � tc (4�6igh Number) <br /> 13. CerUficalion:f celfrfy under penalty of taw t at the fnfdrn ien on this document was prepared to the best of my knowledge and <br /> belie/to be hue,accurate and complete. {Y <br /> SIGNATUREi(handwritten) Dale -AV i r <br /> Name(prnt) 7L�7 C - TRIe LQA Phone OG I S <br /> DTSC Form T358{49/18) <br /> Page 3 df3 <br /> Tricia Dai, EHS Page 1 of 1 <br />