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<br />CONSTRUCTION AGGREGATE <br />INDUSTRIAL WASTEWATER DISCHARGE APPLICATION <br />FOR AGENCY USE <br />APPLICATION NUMBER <br /> <br />DATE RECEIVED <br />/ / / / / / / <br />YEAR MONTH DAY <br />Do not attempt to complete this form before reading the accompanying instructions. <br />PLEASE PRINT OR TYPE <br />NEW OR RENEWAL (eziating permit No. ) <br />1. Name, address, and telephone number of the owner of the facility producing <br />discharge. <br />Property owner(s) <br />Telephone Number ( ) <br />Mailing Address <br />Street Address <br />City State <br />County Zip Code <br />Name of Operation <br />Local Contact (familiar with process) <br />Telephone Number ( ) <br />2. Is the facility operated other than by the owner? YES NO <br />If YES, complete the folloxing: <br />Operator <br />Mailing Address <br />Street Address <br />City State <br />County Zip Code <br />Name of Operation <br />Local Contact <br />Telephone Number ( ) <br />Also, on the back side of this page describe the relationship, <br />agreements and time frame of any agreement. <br />-3- <br />