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h , <br /> d <br /> " MUNICIPAL UTILITIES DEPARTMENT <br /> CITYOF REGIONAL WASTEWATER CONTROL FACILITY <br /> 2500 NAVY DRIVE (209) 937-8750 PHONE <br /> ' <br /> STOCKTON STOCKTON , CA 95206 (209) 937-8702 FAX <br /> GROUNDWATER DISCHARGE PERMIT <br /> PART A — APPLICATION <br /> 1 . Property Information : <br /> Site Address : 12 \ 47 <br /> Property Owner: <br /> If1 C` . oma, BSA C CSO S <br /> Name <br /> Mailing Address City Zip <br /> a Oq . 518 . 3 ��co <br /> Phone (Office) Phone (Cell) Phone (Fax) <br /> 2 . Environmental Consulting Firm : <br /> 1 c�ai�C zsr � rwr.'�o\ Phone 530 , J � (® . LPO <br /> Name <br /> Mailing Address City Zip <br /> Project Manager: <br /> Name Title <br /> SacxSVA - OW? Li S�14z:) . �'\ ot , (aq\ 530 . '07(0 . <br /> Phone (Office) Phone (Cell) Phone ( Fax) <br /> E-mail: t��po ru— C �yn�lhflClC� . ( <br /> 3 . KGl-S <br /> Emergency ontact Name Title/Company <br /> tips. sl� _ o373 <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 /> S gnat ri al Signature Required ) Date <br /> Print Name Title <br />