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<br />• <br />CIAL USE ONLY <br />O <br />Date Seat: /a~~6~9~ <br />Date In: <br />Date to D.E.: <br />Date Recd. from D.E. <br />PERMIT INACTIVATION FORM <br />Facility: CQ/VA/8// ,eE?SOa,eC'PS Legal Contact Person: ~ ~q.eO/ ~titie// <br />Address: ~y~,f S' Ci•~/CO~.v ~~~ Legal phone Number:~O,j> 667-/0~3 ~ <br />Facility Contact: ~-~ m 2 <br />Facility Contact Phone Number: <br />County: ~iP~%1/P~ <br />Permit Number: CQ~- ,`A'DD/Oy <br />Location: 1/1/4 S~_ T~,(~/ R 69/n/ Gyp P/{') <br />Direction: <br />Please answer the following questions sad sign the certification. If you have <br />any questions regarding your facility and the information required, please <br />contact your District Engineer, ~/,•C rO2 Sffi'N L <br />Purpose of Request lYli'N~nIQ LAMP/e7'`Pd• Discharge was to tj/J(~/~~,P [,;P,o <br />-~ <br />1. Is the facility operational? YES NO <br />a. If not, is there any plan to operate the facility <br />in the future? YES NO <br />b. If so, is there an estimate of wheal YES NO <br />Date for' start-up <br />2. If the facility is operational, is any process or other <br />wastewater being produced? How much? gpd YES NO <br />a. If yes, is the water being treated? <br />b. What form of treatment is utilized? Diacusa sizes <br />of unit processes and say chemical additions. <br />c. Is any of the process or any other wastewater or <br />water being discharged to waters of the state? <br />(This includes groundwater in cases like uallned <br />lagoons.) YES NO <br />1. If yes, identify discharge point(s). <br />d. Is the facility designed to be a non~iscbargiag <br />(evaporative) system. YES NO <br />