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APPLICATION <br /> <br />POLLUTION CONTROL FACILITIES <br /> <br /> oF ¢ <br /> ~rATE <br /> <br />Official Name of Applicarit (Owner) <br /> <br /> Mailing Address <br /> City Sine Zip <br /> R*~l]on$ible Official <br /> <br />Address or L~cadon Phone <br /> <br />Briefly ~unmar~e the fa~lity and primm'T method of ~ lxealmmt and disposal. <br /> <br />As EXHIBIT A, am~cl~ two (2) ~opies of a Pr~limimr/ ~ngin~idng ~n or F~ ~ ~n wh~ ~ly ~s ~ pm~s~ pratt, using wfi~n <br /> <br /> t, A compte~ de~n of <br /> 2. ,~e l~on of ~ pmj~t ~ ~nl f~fli~ ~ w~ays, a. ~n Fo~. <br /> 3. ~ule for deveiop~nt, b. <br /> c, D~ of ~M ~ ~ sludgez. <br /> ~ ~he~nc diag~ of ~ s~, ~ ~nt ~ dh~ ~c~i~, 7. O~w~r ~fion. <br /> 5, Si~ Eviction ~n. 8. Ev~n ofg~mr ~ mfface wamr i~c~. <br /> <br />LAND USE COMPATIBILITY STATEMEiVT: is auached [] is coming <br /> <br />Attach a list of o~aer pea~its issued or apptd for. <br /> <br />Regisrranon F~ <br />Sim £valuation Confirmation Fee * <br />PI~ ~ F~ <br />Compli~ ~imdon F~ ~ <br />TOT~ $ <br /> <br />(Or Legally Authoriz~t Repr~enr~tive) <br /> <br />DEQ-WQ-IWSWH4~$,5 (05/95) OVER <br /> <br /> <br />