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I • <br /> 14s' <br /> iso <br /> quWat-1 Number <br /> `51 IZ I T <br /> 52 <br /> 53 <br /> �Slte Code: 1952 <br /> 54 ldzzo- 1 , 411112F- r 11 <br /> 55 Address: 290s U BWAKIN HOLT Contact:' <br /> City; STODGON Zip: 95207 Phone: <br /> 571 <br /> billing/responsible Party Information <br /> lBillino Name: _ Bill Info OK? ! _ <br /> i � I <br /> Address: <br /> City: State: Zip: <br /> Contact: Phone <br /> Property Owner/Operator <br /> s <br /> Nose: Phone: <br /> f(2 Address: <br /> 3 <br /> t shtp! 7i Ile <br /> 1° <br /> IS Client Information (if different from Owner/Operator) <br /> 16 <br /> Kase: Phone: <br /> Address: <br /> a <br /> I,o <br /> Applicant's name, date signed, title <br /> i,2� <br /> _ y <br /> 1,3 Name:.. - .. .. ,i .. Date: <br /> flu Title: <br /> I <br /> "t Consultant Company: STI <br /> e <br /> 91 Other Contact name or Info: Phone: <br /> 123 <br /> 21 <br /> 22 Program Element: 3`.126 Billing Code: Assigned To: HK <br /> 3i <br /> ,2S <br /> 126 Date of Submittal: 03/12193 OT Request:N OT Request Date: <br /> ,2, <br /> i <br /> 2e1 Type of Submittal: 11 Work Plan for Permit Activity <br /> _I; 25 <br /> Check No.ICash <br /> Date Paid <br /> 3, <br /> 134 <br /> Permit Fee Paid 0.00 <br /> i3,11A Check No./Cash <br /> 136i <br /> 13)� <br /> I <br /> ;.313`- Staff Review Due: OT Scheduled: OT Completed: <br /> 6l <br /> Action DateE <br /> Action Date Action Date <br /> f 112 <br /> 431 I fk k/Cos Ltr Recd eyis' DR` <br /> i <br /> i••` MM Comments ep Re CompS�j � Par Due <br /> 145! <br /> �EM Ill <br /> 4C 1 <br /> Add. Info Recvd Denied evlsion Due <br /> �'11:'1j D...ii Ton.. _Ic—;., Gawi�_Sco,ed. I f1F6 a...— Dun <br />