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INDUSTRIAL WASTE PERMIT <br /> APPLICATION FORM <br /> Note : Please read all attached instructions prior to completing this application . <br /> Section A — GENERAL INFORMATION <br /> 1 . Facility Name : <br /> a . Operator Name : <br /> b . Is the Operator identified in 1 . a . the owner of the facility? <br /> Yes ( ) No ( ) <br /> If no , provide the name and address of the operator and submit a copy of the contract <br /> and/or other documents indicating the operator's scope of responsibility for the facility. <br /> 2 . Facility Address : <br /> Street: <br /> City: State : Zip : <br /> 3 , Business Mailing Address : <br /> Street or P . O . Box: <br /> City: State : _ Zip : <br /> 4 . Designated signatory authority of the facility: Attach similar information for each <br /> authorized representative <br /> Name : <br /> Title : <br /> Address : <br /> City: State Zip : <br /> PhnnP#m <br />