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FOR AGENCY USE ONLY <br /> CONSTRUCTION DEWATERING- PERMIT NUMBER <br /> INDUSTRIAL WASTEWATER DISCHARGE APPLICATION C 1 O _ 1 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 ❑ OR RENEWAL ❑ (EXISTING PERMIT NO.) <br /> I. Is application for a short term certification(certification will only be effective for no more than 1 year after issuance)? ❑ <br /> OR <br /> Is application for a regular term certification(certification will be effective for 5 years from issuance)? ❑ <br /> 2. Specify whether owner or operator is making application for the permit. ❑ OWNER, ❑ 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 <br /> FEDERAL TAXPAYER I.D. NUMBER- ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Facility Name <br /> Mailing Address <br /> Street Address <br /> City State <br /> County Zip Code <br /> Telephone Number j 1 Fax. No. <br /> 4. Name,address,and telephone number of the owner of the facility producing the discharge. <br /> Property Owner(s) <br /> Facility Name <br /> Mailing Address <br /> Street Address <br /> City State <br /> County Zip Code <br /> Telephone Number ( 1 Fax. No. <br /> DEWA7EM04/93 (1 <br />