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<br /> <br />OFFICIAL USE ONLY <br />Date Sent: S/S~9 3 <br />Date In: <br />Date to D.E.: <br />Date Recd. from D.E. <br />PERMIT INACTIVATION FORM <br />Facility: 7~oC K~ ~s ~ /P ~O . Legal Contact Person: ffi9•eL/~ iPA,B000,~ <br />Address: Legal Phone NumberC/O T2 R R y /Y7• NE tl /e y'aN <br />~ / (b og) 7s-4 ~3 y / <br />Facility Contact: ,~o8P2T y~eem~4./county:~o~~'r"r' <br />Facility Contact Phone Number:~3o3) permit Number: C'QG - $ S O Oa 3 <br />b'79-7li0 <br />Location: 1/4 S~p~l.d.8,a9T ~-,(/ R• $7G/ <br />3 Y3D / <br />Di/Jrection: ~p~y,'mAre/.~ f0 rrii~eS .rnurhWeST o7~ ,Sl~c/e./ <br />l D IFJ.PO%~~ T <br />Please answer the following questions and sign the certification. If you have <br />nay questions regarding your facility sad the information required, please <br />contact your District Engineer, Trn C'1~,ud,e.' /o <br />Purpose of Request QP8~2/~Y~'OA1S 1.e0$Pr~ Discharge was to ~',Q/~55~ (~ ee <br />1. Is the facility operational? YES NO <br />a. If noc, is there any plan to operate the facility <br />in the future? YES NO <br />b. If so, is there as estimate of when? YES NO N/R <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? Discuss sizes <br />of unit processes sad any chemical additions. <br />c. Is any o£ the process or any other wastewater or <br />water being discharged to waters of the state? ~(//~ <br />(This includes groundwater in cases like unlined <br />lagoons.) YES NO <br />1. If yea, identify discharge point(s). <br />d. Is the facility designed to be a non-discharging <br />(evaporative) system. YES NO <br />