Laserfiche WebLink
MUNNAL UTILITIES DEPARTMENT <br /> REGIONAL WASTEWATER CONTROL FACILITY <br /> a2500 NAW DRIVE <br /> MCKMN, CALIFORNIA 95205 <br /> (209)937-8750 e` <br /> CITY OF STOCIC'MfM FAX (249)937-8708 Part A - Application U / Pere a lit <br /> SECTION 1. APPLICATION <br /> Return the completed application by <br /> Further Instructions See reverse side <br /> Al Applicant Business Name Ul 41 <br /> A2 Address of premise discharging wastewater — <br /> A. Street IF76C <br /> City 5ZQe, Zip <br /> A3 Business Address <br /> A Street <br /> City 4+ c Zip <br /> B Mailing <br /> City State Zip <br /> A4 Chief Executive Officer <br /> A Name &:7--f- S'�G �Z- B Title <br /> C Mailing Address D City'aC-��a StateC. Zip <br /> A5 Person to be contacted about this application <br /> A Name z2E B Title �a f C. Phone <br /> A6 Person to be contacted in case ofemer <br /> A Named 4r �;ll B TitleA!23o __�e��os��f _ --- <br /> .., Night Phone- 2� - - - 7 <br /> Day Phone.��,1��.� � <br /> A7 CERTIFICATION Icertify that the information above and on the following parts is true and correct <br /> to the best of my knowledge. <br /> Signature Date <br /> Print Name Title <br />