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Get Ny Dec 91 19 1 Instructions Form

Permit Issuing Official Becomes a SPDES Permit) PLEASE PRINT OR TYPE APPLICATION TYPE New IF RE-ISSUANCE OR MODIFICATION, GIVE PREVIOUS NUMBER Re-Issuance Modification Clear Form NY --- OWNER S NAME (Corporate, Partnership, Individual) TYPE OF OWNERSHIP Corporate Individual Partnership Public OWNER S MAILING ADDRESS (Street, City, State, Zip Code) REFER ALL CORRESPONDENCE TO: (Name, Title and Address) TELEPHONE NUMBER ( FACILITY NAME FACILITY LOCATION (Street or Road) COUNTY.

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