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IyI <br /> W <br /> {,I ? MUNICIPAL UTILITIES DEPARTMENT <br /> CITY OF REGIONAL WASTEWATER CONTROL FACILITY <br /> 2500 NAVY DRIVE (209) 937-8750 PHONE <br /> STOCKTON STOCKTON, CA 95206 (209) 937-8702 FAX <br /> GROUNDWATER DISCHARGE PERMIT <br /> PART A — APPLICATION <br /> 1 . Property Information : <br /> Site Address: d rs► 7 g` "pcy sy% c• Av S- vQcAt ®fy <br /> Property Owner: <br /> Name <br /> ci e' <br /> Mailing Address City Zip <br /> Phone (Office) Phone (Cell) Phone (Fax) <br /> 2 . Environmental Consulting Firm: <br /> St` s Phone CS''%Qy (®") (L60oLl <br /> Name <br /> Mailing Address City Zip <br /> Project Manager: <br /> D�t�.9rrv� "Ci; rd ✓rr— '�'cv W7�� x]11 � s e. - <br /> Name Title <br /> 3l3 - L42.17 (said la�- Looc s' <br /> Phone (Office) Phone (Cell) Phone (Fax) <br /> E-mail : r;l kii rr C m ice r i:vC <br /> 3 . < Lk-�s 'ice fv1[ua4tmp <br /> Emergen ontact Name " Title/Company <br /> Day Phone Night Phone <br /> 4 . CERTIFICATION : I certify that the information above and on the following parts are true <br /> and correct to the best of my knowledge. <br /> Sig re ((Tr@inal Signature Required) Date <br /> �[�h z�r�ale rn aka" Eraenttrz� <br /> Print Name Title <br />