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ttal !`itiluEr' 4 Da e R e c e i <br /> ;'Site Cone: 1151i{(y Il <br /> (Cite :dame: MOH :-FRY RANCH Lead Agenc•y: L 4 <br /> Address, ?5 INDUSTRIAL W`! � Co-ntact 1 <br /> a <br /> City: STOC ;TOiv iio- Phone- � <br /> Siilig/resgonsiLle Party Infar•mation <br /> }ii i i i !o Name: -:r^ OL''7l <br /> Add--e s=_ : <br /> t <br /> City. State: <br /> �i Ccr,tact . Phone ' <br /> ^.-r y Owner/Operator <br /> 1 Name: Phone.- <br /> Address: <br /> Mone.Address: <br /> 3 City.: State: _3.p- ! <br /> Client Information (if different from Owner/Operator) <br /> Name- Phone: 1 <br /> i <br /> i Addres=_ : I <br /> City: State: 711D: - - <br /> PPQlicant' =_ name; date signed. title <br /> Name. Dat e <br /> Tit_e: WORKPLAN CONTINUED A'S'ST E <br /> Consultant C_mDany, WHF ^ <br /> Contact Name: `hone. i <br /> 0-the•r Contact name or Infer. honc <br /> +� Program clement . =951 j Billinq Cede: I Assigned DH <br /> -i`,_ of --.:bgittaI . MOPKPL PN FOR =ITC 7'==T <br /> Date of Submittal: x}1/1, /9 C ! OT ReC-Uest,: N OT Re4+-,e=_t Da ta: it <br /> jt <br /> `k <br /> iyq'e of Submittal : 11 Work Plan for Permit Activity i! <br /> 11 Permit Fee Paid 'i rrr.; 1 . <br /> ii <br /> Check No. /Cash i <br /> ;4 Date Paid I 4 31 <br /> I ! <br /> 11 Permit Fee Paid <br /> f; <br /> � LPeCi-< No. /Cash <br /> 0 Gate Paid <br /> Staff =review Due. T ' ed ler; _ <br /> O �c t ��_i- � OT Complet__, <br /> I� t 1 <br /> ij 'ACt i ^, Date Act i on Date ` tict I on Dat <br /> L` /C_m If <br /> Re, !Add. n =i eq_ ,� ,p vie <br /> H.C. Com –tS i:ecd !Revision Regste7 <br /> OR DI;E <br /> l!E✓i <br /> "Dtrtr' "='>C';' "tr.- i, N 0r!-iCt10- i FR1� <br /> ii Add. Info Y'�r <br /> .. `id 1Den-1 ed 1 Re`i1.:on' <br /> hermit T ye. MQ /I-qq5 !Special Permit 1ssuec: Ot f r;r�e-.='� O'S✓ i1 <br /> i{�Yi--kc—i. 1�omm e-nt Lt S=ff.. t Li..o ___ <br />