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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 /> Phone#: <br /> 5. Designated facility contact: <br /> Name: <br /> Title: <br /> Phone#: <br /> 1 <br />