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AESCULAP INSTRUMENTS CORP (Continued)
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Receive Date: 1990-02-27 00:00:00.0
Handler Name: AESCULAP INSTRUMENTS CORP
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State District Owner: CA
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AESCULAP INSTRUMENTS CORP
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TC6362151.2s Page 189
/-`' n
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STATE OF ��A`�IFORtvfIA PETE WILSON, Governor
' SAN FF�ANCISCO BAY CONSERVATION AND DEVELOPMENT COMMISSION
THIRTY VAN NESS AVENUE, SUITE 2011 �
SAN FRANCISCO, CALIFORNIA 94102-6080
PHONE: (415) 557-3686
PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FIVE
Fe1Cor/CSS Holdings, L.P.
545 E. John Carpenter Freeway, Suite 1300
Irving, Texas 75062
ATTENTION: Jack Eslick
Ladies and Gentlemen:
On Apri121, 1983, the San Francisco Bay Conservation and Development Commission, by a
vote of 18 affirmative, 0 negative, and 1 abstention, approved the resolution pursuant to which the
original permit had been issued. Moreover, on September 7, 1983, July 23, 1985, October 24,
1986, a� April 19, 1988, and Janua� 27. 1997, pursuant to Regulation Section 10822, the
Executive Director approved Amendment Nos. One, Two, Three, a� Four, and Five,
respectively, to which this amended permit is hereby issued:
I. Authorization
A. Subject to the conditions stated below, the permittee is granted permission to do the
following within the Bay and within the 100-foot shoreline band, at 150 Anza Boulevard, on
Assessor's Pazcel Nos. 26-342-220, 26-342-230, and 26-342-240, immediately west of Anza
Lagoon in the City of Burlingame, San Mateo County:
1. Within the Bay:
a. Place storm drain outfall pipes;
b. Place 4,500 cubic yards of new riprap for shoreline protection purposes and
repair and remove reinforced bar from existing riprap where necessary, along the
1,SOO linear feet of Bay shoreline; and
Construct and use a 60-foot-long, 3,400-square-foot fishing pier.
2. Within the 100-foot Shoreline Band:
a. Construct and use a 4,300-square-foot portion of a 51,634-square-foot hotel;
b. Construct and use a 4,353-square-foot portion of a 9,000-square-foot
combination restaurant/public services building;
c. Construct and use an approximatelY 704-square-foot shop and storage buildin�
attached to the hotel (Amendment No. Five); ��� p�;;�' ��i ,
� � � � � �` �r.,v !: _ .
JAN 2 � 1997
Dedicated to making San Francisco Bay better. CITY Ga �i.;l;[_Ii'.'+:,;-�v',F_
PLANivl�,!(: isi��[
�
� PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FIVE
Fe1Cor/CSS Holdings, L.P.
Page 2
e<l. Place and use t00,260 square feet of paving for vehicle circulation and 103 of the
430 parking spaces;
de. Place 8,300 cubic yards of clean earth fill, landscape and use 171,056 square feet
(3.92 acres) for public access inclu�iing 109,336 square feet (2.5 acres) for a park
along the Bay shoreline; and;
ef. Install, landscape, and use 54,050 square feet (1.24 acres) for public access
around the southeastern shoreline of Anza Lagoon.
B. This amended authority is generally pursuant to and limited by your application dated
February 14, 1983, and your letters dated August 31, 1983, requesting Amendment No. One, May
22, 1985, requesting Amendment No. Two, July 10, 1986, requesting Amendment No. Three,
a� February 22, 1988, requesting Amendment No. Four, and October 23. 1996, requesting
Amendment No. Five, including all accompanying and subsequent exhibits, ��xg attached
Exhibits A, B, and C at�ae�e�, but subject to the modifications required by conditions hereto
attached.
C. Work authorized herein for the project must commence prior to September 1, 1984, or this
amended permit will lapse and become null and void. Such work must also be diligently
prosecuted to completion, and must be completed by January 1, 1987, unless an extension of time
is granted by further amendment of this amended permit prior to its expiration. Work authorized
herein for Amendment No. Four must commence prior to July 1, 1988, and must be completed by
July 1, 1989. Work authorized by Amendment No. Five must commence prior to Mav 1. 1997.
D. This project will provide approximately 5.16 acres (225,106 square feet) of landscaped
public access improvements within the 100-foot shoreline band, and in addition, will provide
approximately 5,600 square feet of landscaped public access outside the 100-foot shoreline band,
along 1,SOO linear feet of Bay shoreline and 2,0201inear feet of lagoon shoreline in the City of
Burlingame, San Mateo County.
II. Special Conditions
The amended authorization made herein shall be subject.to the following special conditions, in
addition to the standard conditions in Part IV:
A. Specific Plans and Plan Review
1. Plan Review. No construction or use whatsoever shall be made of any facility
authorized herein, until final precise site, grading, architectural, and landscaping plans,
and any other relevant criteria, specifications, and plan information for that portion of
the work have been submitted to, reviewed, and approved in writing by or on behalf of
the Commission for work authorized throug,h Amendment No. Four. No plan review is
required for Amendment No. Five.
a. Architectural Plans. Architectural plans submitted for review shall consist of
exterior elevations with building details which indicate the location, dimensions,
exterior treatment, and color of all structures, outside signs, and other fixtures.
PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FIVE
Fe1Cor/CSS Holdings, L.P.
Page 3
b. landscaping Plans. Landscaping plans shall be prepared and signed by a
licensed landscaped architect and may be submitted as part of the architectural
plans or submitted separately. In either case, such plans shall consist of grading,
staking, planting, and irrigation sheets showing the location, types and
dimensions of all pathways, public access areas, structures, parking spaces,
benches, tables, trash containers, lighting, and a list of the names and quantity of
all plant species to be used.
Architectural and landscaping plans submitted for review shall be accompanied by a
letter requesting plan approval, identifying the type of plan submitted, the portion of the
project involved, and indicating whether the plan is final or preliminary. Approval or
disapproval shall be based upon (a) completeness of the plan in showing the features
required above, (b) consistency of the plan's criteria and information with the specific
terms and conditions of this amended permit, (c) ma,�cimi�ing the attractiveness of the
public access area, and (d) consistency of the plan with the recommendations of the
Design Review Board. In each instance, plan review shall be completed, by or on
behalf of the Commission, within 45 days after receipt of the plan or plans to be
reviewed, and shall consist of a letter specifically referring to the submitted plan or
plans which indicates whether it or they have been approved or disapproved.
2. Changes to Approved Plans. After final plans have been approved pursuant to Special
Condition II-A-1, no change shall be made to such plans without first obtaining written
approval of the proposed change by or on behalf of the Commission. Approval or
disapproval shall be made within 30 days after the proposed change has been submitted
for approval and shall be based on a finding that the change complies with this amended
pernut and would not detrimentally affect public access, landscaping, open space, open
water, or other public benefits.
3. Conformity with Approved Plans. All leases, contract specifications, and all structures
and improvements at the project site shall conform to the final plans approved pursuant
to this special condition. No structures shall be placed nor any improvement undertaken
that is not clearly shown and indicated on the approved final plans. After construction,
no noticeable changes to the exterior of any structure shall be made, no additional
structure shall be built, nor shall park, open space, open water, landscaping, or public
access areas be altered without first obtaining written approval by or on behalf of the
Commission pursuant to Special Condition II-A-2.
B . Public Access
Area, Prior to the commencement of construction authorized herein, and including the
construction of improvements authorized by Amendment No. Four, the permittee shall,
by instrument or instruments acceptable to counsel for BCDC, dedicate to a public
agency or otherwise guarantee rights for the public for access or walking, sitting,
viewing, iishing, picnicking and other related purposes, to the areas generally shown
on Exhibits A and C as public access, and prior to use or occupancy of any facility
authorized herein and until this amended perm.it is further amended such areas shall
remain available to the public for such uses.
2. Instrument. An instrument submitted to counsel for BCDC's approval pursuant to
Special Condition II-B-1 shall create rights in favor of the public, at least to the extent
of the permittee's interest in the existing lease to the site, for the purposes indicated and
PERMIT NO. 6-83
(Issued on April 25, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FNE
Fe1Cor/CSS Holdings, L.P.
Page 4
shall include a map that shows the property lines and dimensions of such areas, and
contains a metes and bounds description of the azeas. The instrument shall be in a form
suitable for recording in the county where the property is located. Approval or
disapproval of the instrument shall occur within 30 days after submittal for approval
and shall be based upon the sufficiency of the instrument to create the rights and duties
indicated in the special condition. Within 60 days after approval, the pernuttee shall
record the instrument and shall provide evidence of recording to the Commission.
3. Improvements. Prior to the use or occupancy of any facility authorized herein, the
pernuttee or its assigns, shall complete the following public access improvements,
substantially in accord with preliminary landscape plans entitled "Granada Royale
Hometels (Embassy Suites)," dated August 24, 1986, prepared by Blunk Associates,
Architects and Callander Associates, Landscape Architects. The public access
improvements authorized by Amendment No. Four, and as described in (c) below,
shall be constructed and completed substantially in accord with the preliminary
landscape plan entitled "Pazcel 10 Shoreline, Preliminary Site Development Plan,"
dated February 22, 1988, prepared by Callander Associates Landscape Architects:
a. Construction of a 60-foot-long, 3,400-square-foot wooden fishing pier on the
Bay shoreline as shown on Exhibit B, attached;
b. Placement of 171,056 square feet of landscaped public access improvements
along the Bay and Anza Lagoon shorelines, including a 2.5-acre park on the
peninsula as shown on Exhibit B, attached;
c. Placement of 54,050 square feet (1.24 acres) of irrigated landscaped public access
improvements along the southeast shoreline of Anza Lagoon as shown on Exhibit
C attached.
d. Placement of a 3,520-lineaz-foot, 10-foot-wide pedestrian/bicycle pathway
system along the Bay and Anza Lagoon as shown on Exhibits B and C, attached;
e. Placement of benches and trash receptacles within the public access areas at
locations approved pursuant to Special Condition II-A-1;
Placement of six public access signs, one public �shing sign, and approximately
seven public parking signs of a size, design, and with information approved by or
on behalf of the Commission placed at locations approved pursuant to Special
Condition II-A-1;
g. Placement of not less than 20 designated public parking spaces at locations
approved pursuant to Special Condition II-A-1; and
h. The public restroom facilities shall be readily identifiable from the shoreline,
remain open during daylight hours, and be free of charge.
4. Maintenance. All areas and improvements required by Special Condition II-B
including landscaping, signs and public paths shall be permanently maintained by, and
at the expense of, the permittee, any assignees, lessees, and sublessees. Maintenance
PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FIVE
Fe1Cor/CSS Holdings, L.P.
Page 5
shall include repairs to all path surfaces, replacement of any plant material that dies or
becomes unkempt, periodic clean-up of litter and other materials, and assuring that
public access signs remain in place and visible. Within 30 days after notiiication by
staff, the permittee shall correct any maintenance deficiency noted in a staff inspection
of the site.
5. Riprap. Prior to use of any facility authorized herein, the permittee shall remove all
debris and any exposed reinforcing bar from the riprap along the shoreline and dispose
of such outside of the Commission's jurisdiction.
C. Permit Recording. Prior to the commencement of construction, the pernuttee shall record
this amended pernut or a notice referring to this amended pernut in accordance with applicable
provisions of Government Code Section 27291.5 with San Mateo County and shall provide
evidence of recording to the Commission.
III. Findings and Declarations
This amended authorization is based upon the Commission's findings and declarations that the
work authorized herein is consistent with the McAteer-Petris Act, the San Francisco Bay Plan, the
Commission's Amended Management Program for San Francisco Bay, and the California
Environmental Quality Act for the following reasons:
A. Use. San Francisco Bay Plan Map No. 9 does not designate the site for any priority use.
However, a Bay Plan note for the City of Burlingame states: "Prepare precise plan and
development program for waterfront; include continuous public access to Bay shoreline for
viewing and fishing. Some fll may be needed." As the Bay Plan Map does not designate the site
for a priority use, the proposed project is compatible with the use requirements of the Bay Plan.
B. Fill for Fishing Pier. The pernuttee has proposed a 3,400-square-foot fishing pier along the
Bay side of the project. Although the fishing pier does not extend to deep water, the Commission
finds that it will improve fishing opportunities along this section of shoreline which is now heavily
used by iishermen. The Commission further notes that this section of the Bay shoreline of the
Anza Airport Park Subdivision is approximately 2,000 feet long (of which about 1,500 feet are
within this site) and is essentially straight. The Design Review Board accepted the pernuttee's
assertion that the construction of the fishing pier would introduce some variety into this otherwise
long, straight shoreline. Although such variety could be provided by other means, such as
excavating a portion of the shoreline, the Commission finds that such an alternative would not also
serve the purpose of improving fishing. Therefore, the Commission finds that the purposed fishing
pier constitutes a water-oriented recreational use for which some iill may be authorized and minor
fill to improve shoreline appearance and public access.
C. Public Access. The 15.74-acre site is bounded by the Bay to the north, Anza Lagoon to
the east, and existing development is located to the west and south. The long, irregularly-shaped
pazcel forms a peninsula at its eastern end and includes a strip of land totaling 1.24 acres on the
southeast shoreline of the Lagoon. About 4.6 acres of the 15.74-acre site are in Anza Lagoon. The
project site has 1,SOO linear feet of Bay shoreline and 2,0201inear feet of Lagoon shoreline. Of the
11.14-acre dry land portion of the site, 6.64 acres are located within the 100-foot shoreline band.
The site is flat and supports no significant plant or animal life except within the Lagoon and in the
marsh vegetation along its edge.
�PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FNE
Fe1Cor/CSS Holdings, L.P.
Page 6
The permittee proposes a total of 5.36 acres of public access improvements on the 11.14 acres
of dry land at the site. An additiona15,600 square feet outside the Commission's jurisdiction will
also be improved for public access. Approximately 6,000 square feet of the ground floor area of
the restaurant structure will be used for public services and some commercial uses. The hotel is
located, at its closest point, 60 feet from the shoreline, and the restaurant structure is located about
50 feet from the shoreline. The minimum width of the public access area is 35 feet, adjacent to a
portion of the public parking. Public access improvements consist of a 10-foot-wide pathway
running along 3,5201ineaz feet of Bay and Lagoon shoreline. Public access improvements along
the southeastern shoreline of Anza Lagoon consist of a 54,050-square-foot (1.24 acres) landscaped
area including a 10-foot-wide, 720 foot long pedestrian/bicycle pathway system along the Lagoon
edge and a 4,600-square-foot paved plaza area furnished with benches and a trash receptacle.
Public access widths vary from a minimum of 30 feet to over 100 feet along this portion of the
Lagoon. A 2.5-acre park is located at the end of the peninsula and a 60-foot-long, 3,400-square-
foot fshing pier is located across from the combined restaurandpublic services building. The
remainder of the shoreline is landscaped, with public access widths varying from a minimum of 35
feet to a maximum of over 100 feet.
The Commission adopted public access guidelines for the Anza azea. The guidelines state that
an important access azea should be developed on the peninsula of this site. In addition, public
access widths along the Bay shoreline should average 75 feet wide with a minimum width of 40
feet or the height of the adjacent building. The minimum and average widths proposed are slightly
less and the public access next to the hotel is less than its height. However, the guidelines also
state: "Any exceptions to the minimum widths of public access areas shall be allowed only if the
design of the building and adjacent public access is such that the public is encouraged to make
greater use of the shoreline and other substantial public access azeas are provided to offset the
reduction in the minimum width...." An exhibit to the guidelines shows a conceptual plan for the
development of the site similar to that proposed in this application with a major public access area
on the peninsula which is the most important part of the site. The 2.5-acre pazk area on the
peninsula, the 3,400-square-foot fishing pier, and the 1.24-acre of public access along the
southeastern shoreline of Anza Lagoon offset the differences in the average and minimum widths
of public access listed in the guidelines and conform to the conceptual plan accepted by the
Commission as a reasonable alternative. Furthermore, during the Commission's review of the
public access guidelines, the conceptual project plan for the site involved a restaurant on fill. The
restaurant was perceived as an obstacle to public access, however, and the Commission stated that
no portion of the structure should be located on iill. In finalizing the design of the project, the
permittee relocated the restaurant so that not only was no �11 involved but is now 50 feet from the
Bay allowing unobstructed access along the shoreline.
Therefore, the Corrunission iinds that the 2.5-acre park, the public amenities provided in the
restaurant structure, the fishing pier, and the 1.24-acre public access area on the southeastern
shoreline of Anza Lagoon will provide a variety of public access amenities, will provide
continuous public access to and along the shoreline and will improve a significant fishing area
along the Bay and, therefore, is the maximum feasible public access consistent with the proposed
project.
D. Public Trust. By this amended permit, the Commission deternunes that the proposed project
is consistent with public trust needs.
PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FIVE
Fe1Cor/CSS Holdings, L.P.
Page 7
E. Traffic. Working with Commission staff, the Metropolitan Transportation Commission
(MTC) has recently completed a study relating recently proposed developments east of Highway
101 with the already strained capacity of that freeway. Highway 101 is already at capaciry in
several sections and the study concluded that if all the projects proposed for development east of
the freeway are completed, traffic on Highway 101 may exceed capacity by 40 percent at peak
hours. If that takes place, there will obvioizsly be pressure to either widen the freeway or construct
a new expressway to the east of the existing freeway. Either would require extensive fill in the
B ay.
The Commission fnds that this project should not be treated as a precedent or encouragement
for the authorization of such fill beyond that considered by the Commission in adopting the public
access guidelines for this subdivision. No policies have yet been adopted to deal with the overall
issue of traffic generation east of Bayshore and there is little evidence to suggest that this project by
itself will lead to additional fill in the Bay. Moreover, the public access proposed is consistent with
the Commission's public access guidelines for this area. Consequently, the Commission finds the
project to be consistent with the Bay Plan and the McAteer-Petris Act. However, the Commission
also recognizes that some policies will have to be developed in coordination with affected local,
state, and regional agencies to deal with the overall problem to avoid the major fills that might take
place if no other transit or planning alternatives are chosen
F. Environmental Impact. The City of Burlingame, the lead agency, certified the
Environmental Impact Report for the proposed project on January 3, 1983. Pursuant to Regulation
Section 11501, Amendment Nos. One, Two, Three, a� Four and Five are categorically exempt
from the requirement to prepaze an environmental impact report.
G. Conclusion. For all these reasons, the project provides maximum feasible public access
consistent with the proposed project. The Commission further finds, declares, and certifies that the
activities authorized herein are consistent with the Commission's Amended Management Program
for San Francisco Bay, as approved by the Department of Commerce under the Federal Coastal
Zone Management Act of 1972, as amended.
IV. Standard Conditions
A. All required permissions from governmental bodies must be obtained before the
commencement of work; these bodies include, but aze not limited to, the U. S. Army Corps of
Engineers, the State Lands Commission, the Regional Water Quality Control Board, and the city
andlor county in which the work is to be performed, whenever any of these may be required. This
amended permit does not relieve the permittee of any obligations imposed by State or Federal law,
either statutory or otherwise.
B. The attached Notice of Completion and Declaration of Compliance form shall be returned to
the Commission within 30 days following completion of the work.
C. Work must be performed in the precise manner and at the precise locations indicated in
your application, as such may have been modified by the terms of the amended perm.it and any
plans approved in writing by or on behalf of the Commission.
� PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FIVE
Fe1Cor/CSS Holdings, L.P.
Page 8
D. Work must be performed in a manner so as to minimize muddying of waters, and if diking
is involved, dikes shall be waterproof. If any seepage returns to the Bay, the permittee will be
subject to the regulations of the Regional Water Qualiry Control Board in that region.
E. The rights, duties, and obligations contained in this amended permit aze assignable. When
the permittee transfers any interest ir� any property either on which the authorized activity will occur
or which is necessary to the full compliance of one or more conditions to this amended pernut, the
pernuttee/transferor and the transferee shall execute and submit to the Cominission a pernut
assignment form acceptable to the Executive Director. An assignment shall not be effective until the
assignee executes and the Executive Director receives an acknowledgment that the assignee has
read and understands the pernut and agrees to be bound by the terms and conditions of the
amended pernut, and the assignee is accepted by the Executive Director as being reasonably
capable of complying with the terms and conditions of the pernut.
F. Unless otherwise provided in this amended permit, all the terms and conditions of this
amended pernut shall remain effective for so long as the amended pemut remains in effect or for so
long as any use or construction authorized by this amended pemut exists, whichever is longer.
G. Unless otherwise provided in this amended pernut, the terms and conditions of this
amended permit shall bind all future owners and future possessors of any legal interest in the land
and shall run with the land.
H. Unless otherwise provided in this amended pernut, any work authorized herein shall be
completed within the time limits specified in this amended permit, or, if no time limits are specified
in the amended permit, within three years. If the work is not completed by the date specified in the
amended permit, or, if no date is specifed, within three years from the date of the amended pernvt,
the amended pernut shall become null and void. If a pemut becomes null and void for a failure to
comply with these time limitations, any fill placed in reliance on this amended permit shall be
removed by the permittee or its assignee upon receiving written notification by or on behalf of the
Commission to remove the fill.
I. Except as otherwise noted, violation of any of the terms of this amended permit shall be
grounds for revocation. The Commission may revoke any amended pernut for such violation after
a public hearing held on reasonable notice to the pernuttee or its assignee if the amended pernut has
been effectively assigned. If the amended permit is revoked, the Commission may determine, if it
deems appropriate, that all or part of any fill or structure placed pursuant to this amended pernut
shall be removed by the permittee or its assignee if the amended pernut has been assigned.
J. This amended permit shall not take effect unless the pernuttee executes the original of this
amended pernut and returns it to the Commission within ten days after the date of the issuance of
the amended pernut. No work shall be done until the acknowledgment is duly executed and
returned to the Commission.
K. Any area subject to the jurisdiction of the San Francisco Bay Conservation and
Development Commission under either the McAteer-Petris Act or the Suisun Marsh Preservation
Act at the time the amended pernut is granted or thereafter shall remain subject to that jurisdiction
notwithstanding the placement of any fill or the implementation of any substantial change in use
authorized by this amended permit.
PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FNE
Fe1Cor/CSS Holdings, L.P.
Page 9
L. Any area not subject to the jurisdiction of the San Francisco Bay Conservation and
Development Commission that becomes, as a result of any work or project authorized in this
amended pernut, subject to tidal action shall become subject to the Commission's "bay" jurisdic-
tion.
M. Unless the Commission directs otherwise, this amended pernut shall become null and void
if any term, standard condition, or special condition of this amended pernut shall be found illegal
or unenforceable through the application of statute, administrative ruling, or court deternunation. If
this amended pernut becomes null and void, any iill or structures placed in reliance on this
amended permit shall be subject to removal by the permittee or its assignee if the amended permit
has been assigned to the extent that the Commission determines that such removal is appropriate.
Any uses authorized shall be terminated to the extent that the Commission deternunes that such
uses should be ternunated.
Executed at San Francisco, California, on behalf of the San Francisco Bay Conservation and
Development Commission on the date first above written.
WII.L TRAVIS
Executive Director
San Francisco Bay Conservation and
Development Commission
By: �'` !
-STEVEN A. McAD
Deputy Director
SAM/JGJ/vm
cc: U. S. Army Corps of Engineers, Attn: Regulatory Functions Branch
San Francisco Bay Regional Water Quality Control Board,
Attn: Certification Section
Environmental Protection Agency, Attn: Mike Monroe, W-3-3
City of Burlingame Planning Department
State Lands Commission, Attn: Fred Sledd
Kendall G. Petterson, Architect
Embassy Suites, Attn: Bob Burns
� . � .
r
- � PERMIT NO. 6-83
� (Issued on Apri125, 1983, As
Amended Through January 27, 1997)
AMENDMENT NO. FIVE
Fe1Cor/CSS Holdings, L.P.
Page 10
* * * * * * * * * * * * * * * * * * * * * * *
Receipt acknowledged, contents understood and agreed to:
Executed at
Applicant
On
:
Title