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<br /> Exhibit A <br /> WASTEWATER SURVEY FOR NONRESIDENTIAL ESTABLISHMENTS: <br /> APPLICATION FOR WASTEWATER DISCHARGE PERMIT <br /> SECTION A - GENERAL INFORMATION <br /> A.l. Company na.rne, mailing address, and telephone number: <br /> <br /> <br /> Zip Code Telephone No. <br /> A.2. Address of production or manufacturing facility. (If same as <br /> above, check [].) <br /> <br /> Zip Code Telephone No. <br /> A.3. Name, t it Ie, and telephone number of person authorized to <br /> represent this firm in official dealings with the City: <br /> <br /> A. 4. Alternate person to contact concerning information provided <br /> herein <br /> Name Title Tel.No. <br /> A. 5. Identify the type of business conducted (auto repair, machine <br /> shop, electroplating, warehousing, painting, printing, meat <br /> packing, food processing, etc.). <br /> <br /> Note to Signing Official: In accordance with Title 40 of the <br /> Code of Federal Regulations Part 403 Section 403.14, information <br /> and data provided in this questionnai=e which identifies the <br /> nature and f=equency of discharge shall be available to the <br /> public without restriction. Requests for confidential treatment <br /> of other information shall be governed by procedures speci:ied in <br /> 40 CFR Part 2. <br /> - r <br /> This is to be signed by an authorized official of your fi=m <br /> after adequate completion of this form and review of the <br /> information by the signing official. <br /> I have personally examined and a.rn familiar with the <br /> information submitted in this document and attac~~ents. <br /> Based upon my inquiry of those individuals immediately <br /> responsible for obtaining the information reported <br /> here, I swear that the submitted information is true, <br /> accurate and complete. I am aware that the re are <br /> signi:icant penalties for submitting false information, <br /> including the possibility of fine and/or i:nprisonment. <br /> Date Signature of Off~cial <br /> (Seal if aDplicable) <br /> <br /> -7- <br />