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~y ., <br />..- _ • . <br />r • <br />P.03 <br />STORH wATSR 11ISCHARGS PERMIT APPLICATION <br />/ / / / / / / / / / / <br />naTA uECF-T31E~._ <br />/ / / / / / / <br />YEAR, MONTH DAY <br />PL&4SH PRINT OR TYPE <br />1. Name, ad[ireae. and telephone number of the ovrner of the facility producing <br />discharge. <br />Property Owner(s) <br />Phone NumberLo~33 --7~7~ ~._.rgeacy No. ~~~~ ~9,Z--724 <br />Area Code <br />Mailing AddreaH n_ Q_ x 440 <br />Street AcidrBaH i teratatA 90 ~~ar~enr[ Aveni~ <br />City _$fpi~'e2 tY State Sn Zip Code 57709 <br />2. IH the facility operated other then by the owner? <br />No <br />Yea ~_ Operator (~,Al)f) L•2EN_ ,~, DiVIRTO~) OF PErS <br />Phone No_ ('~0~1 4q'~-7017 emergency No. ~! <br />Meiling Address P_ 0 Bex 1981 <br />Street Address 1B?3o Ne fih 1 c Hi hwav B7 <br />City Laporte State ~'dL Zip <br />IH owner _~or operator <br />Baking application for the permit? <br />3_ Location.af facility: <br />Legal de[ecriptign (Township, Binge. 1/4 Sec_) <br />Stre®t - <br />City _l.ivarmere State Cd <br />Local Contact (familiar pith facility) dam 7.i an r+'nrha <br />Telephono Number (~OS1 49;~ X017 <br />Name of operation Nlee,yer An rrv _ <br />Bireetior:a to the operation from a nearby town or landmark: <br />4- Do you have ari existing CDPS Permit? No ~„ Yea (CO- ) <br />