Laserfiche WebLink
10/26/2001 15:0g 20993761'27 5TORMWATER PAGE 02 <br /> MUNICIPAL UTILITIES DEPARTMENT <br /> REGIONAL WASTEWATER CONTROL FACILITY <br /> of rA 2500 NAVY DRIVE <br /> iz# SmcKTON, CAUFCANIA PUN <br /> (209)937.6750 Part A - Application / Permit <br /> CITY c3F FAX.(209)937-8706 <br /> SECTION 1. APPLICATION <br /> Return the completed application by: <br /> Further Instructions: See reverse side. Alo, 9 S <br /> AI. Applicant Bvsinew Name "z— <br /> A2. Address of premise dischar ing w8stewa r: <br /> A. Street <br /> City Zip <br /> A3. Business Address <br /> A. Street <br /> City Zip.^Q,��`7C� --. — <br /> g_ Mailing <br /> State Zip <br /> City <br /> A4. Chief ? <br /> A. Nance S.Title <br /> C. Mailing Address..--- D. City State— Zap <br /> A6. Person to b�,con�e tad about this application q) 6 g�� <br /> C. P <br /> 't-,�, lyanex Z — <br /> A. Nerve <br /> AS. Person to be contacted in case of emergency { <br /> A. Name M- B.Title <br /> Day Phone4 ` Night Phone CAZ' <br /> A7. CPRTIFICATION = icertify that the information above and on the following Baru is true and correct <br /> to the best of my knowledge. <br /> Signature Dale <br /> Print Name Title <br />