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STATE OF CALIFORNIA <br /> APPLICATION <br /> FOR <br /> DOMESTIC WATER SUPPLY PERMIT AMENDMENT <br /> FROM <br /> Applicant: TA C IC V.e✓d1eV4.V" -P— <br /> [Enter the name of legal owner,person(s)or organization) P 0 F r <br /> Yb H �Y, P� <br /> Address: SG LDc �r. <br /> e �V !•� . �' S141 sun"1[q <br /> System Name:_ F-VCkc_ �-��oyrSe �� � sys7�►+� rr� <br /> System Number: = .� <br /> r � <br /> TO: Department of Health Services + <br /> Drinking Water Field Operations Branch <br /> (Address) AL r F O'S N� <br /> Pursuant and subject to the requirements of the California Health and Safety Code, <br /> Division 104, Part 12, Chapter 4 (California Safe Drinking Water Act), Article 7, Section 116550, <br /> relating to changes requiring an amended permit, application is hereby made to amend an <br /> existing water supply permit to 1 KC/'t/e Gk. yCccJy�l�!N] /41 <br /> (Applicant must state specifically what is being applied for-whether to construct <br /> new works,make alterations or additions in works or sources, or change or modify treatment.) <br /> Z P-es fro oPKS ". l sfrr•,� ,�� �d ev �, d <br /> 1,iea v 5'Li o <br /> (We) declare under penalty of perjury that the statements on this <br /> application and on the accompanying attachments are correct to <br /> FOR OFFICIAL USE my (our) knowledge and that I (we) are acting under authority and <br /> direction of the responsible legal entity under whose name this <br /> application is made. <br /> Date Received: <br /> Signed By: <br /> Title: Al v <br /> Address: 2 7 V,3 A,"6ey1.7 P" <br /> Seblk Oki 64 <br /> Telephone: -7<W7, 1 '96e <br /> Dated: I 7- 0 G DDw:05/2000 <br />