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INDUSTRIAL WASTEWATER DISCHARGE APPLICATION <br />FOR AGENCY USE <br />APPLICATION NUMBER <br />/ / / / / / / / / / / <br />~~ ~, ~~~~ <br />DATE RECEIVED <br />/ r~1AY'J 1987 <br />/ YEAR /MONTH / DAY / RE(; ~'1PJt:l~ SAND <br />~HPA,~Ti~ <br />N DiV{g{ N <br />Do not attempt to complete this form before reading the accompanying instructions. <br />P/LEASE PRINT OR TYPE <br />NEW V OR RENEWAL (existing permit No. ) <br />1. Name, address, <br />discharge <br />Prop <br />Mail <br />Stre <br />City <br />Coun <br />Name <br />Local contact(familiar with process) ~_~~/ai ~ <br />• Telephone Number (~3) ZS`/ ' 32(D ~ <br />Area Code ~~ <br />2. Is the facility operated other than by the owner? YES '" NO <br />If YES, complete the following: <br />Operator <br />Hailing Address <br />Street Address <br />CSty State <br />County 21p 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. (This information may be <br />designated "confidential".) <br />3. Specify whether owner or operator ie making application for the permit. <br />~3aZ <br />ri i• / <br />• (1) <br />and telephone number of the owner of the facility producing <br />