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MUNICIPAL UTILITIES DEPARTMENT <br /> OOA REGIONAL WASTEWATER CONTROL FACILITY <br /> 2500 NAVY DRIVE - <br /> STOCKTON, CALIFORNIA 95206MZ# �+ <br /> (209) 937-8750 <br /> STOCKTON FAX: (209)937-8708 Part A - Application / Permit <br /> CITY OF <br /> SECTION 1. APPLICATION <br /> Return the completed application by: <br /> Further Instructions: See reverse side. <br /> Al. Applicant Business Name .�n('0 0- C nL20i 4j <br /> (20 P <br /> 'a c n P r <br /> A2. Address of premise discharging wastewater: 4/ <br /> A. Street 'V4 Y3 &, <br /> City <br /> A3. Business Address <br /> A. Street E. Fre ,a,tf S <br /> City— Zip 9Sd /.5, <br /> B. Mailing - rre^ Ic 97- <br /> city State Zip-- 9Sa i� <br /> A4. Chief Executive Officer <br /> A. Name Hel r+1 B. Title <br /> C. Mailing Address U S = r r e D. City 0`jr10 State L'rT Zip 9 L76 <br /> A5. Person to be contpcted aboy�t this application <br /> A. Name ZYo r f (eJb' B. Title mu'"� ' Mrs" c e '_C. Phone Sy6-0/// <br /> A6. Person to be co tacted in c�{e f emergency JIq <br /> A. Nameyh i ITY, h B. Title /�u i - 4(- /Y)4 1 ec <br /> Day PhoneZa47'S'y/6- o7//,6Kf //Z Night Phone Zo9-6/S�'3ZS6 <br /> A7. CERTIFICATION : (certify that the ir�rmation above and on t e following parts is true and correct <br /> to the best of my knowledge. - U <br /> /t,0♦J /, a00� <br /> Signature Date <br /> Print Name Title <br />