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FOR AGENCY USE ONLY <br /> CONSTRUCTION DEWATERING- PERMIT NUMBER <br /> INDUSTRIAL WASTEWATER DISCHARGE APPLICATION C O - 0 <br /> DATE RECEIVED <br /> YEAR MONTH DAY <br /> Do not attempt to complete this form before reading the accompanying instructions. PLEASE PRINT OR TYPE <br /> NEW 19 OR RENEWAL ❑ (EXISTING PERMIT NO.) <br /> 1. Is application for a short term certification(certification will only be effective for no more than 1 year after issuance)? lK <br /> OR <br /> Is application for a regular term certification(certification will be effective for S years from issuance)? ❑ <br /> 2. Specify whether owner or operator is making application for the permit. ❑ OWNER, La OPERATOR <br /> 3. Name,address,and telephone number of the person or persons that are responsible for the permit,and to whom this permit should be <br /> sent. Note:The person or persons that are responsible for the permit will be required to sign Item 21 of this application. <br /> Company Name_ Co L y2/+na D t v I S tvti pF lit- e/L-f(S /j-,, 9 co/0lr7 <br /> FEDERAL TAXPAYER I.D. NUMBER- ME] ❑ © ® ® 0 0 9❑ <br /> Facility Name G v mac- /SAS 1" 17..rc 4 C2 ee/T 0 t eRSlr.N P/I J e C <br /> Mailing Address f 4 V & G—S <br /> Street Address <br /> city_ C-9.4,P T f cti State CCI I&R"'P <br /> County /y e S 4 Zip Code 3T&L`' 3 <br /> Telephone Number (Qly) Fax. No. 9 7 v -a 4/—/ S7 6 <br /> 4. Name,address,and telephone number of the owner of the facility producing the discharge. <br /> Property Owner(s) V ti! T t 0 ST.4/e,S Fv/1 e 5 T ,S�/t L, e <br /> Facility Name C0-ft- 13R-5/ti !7.rr- CRetlT DiVe f5 <br /> Mailing Address y 6'X 3 0 9 <br /> Street Address <br /> City C 4-/1 State Cc,!e'/1'¢/Jy <br /> County G 4W Gt<cO Zip Code Fi t< ¢j <br /> Telephone Number (Q1U ) ?G 3— 2 -z Fax. No. <br /> DEWATEMG IN3 (1 <br />