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Phone (225) 219-3051 Fax (225)219-3156 Shaded boxes for LDEQ Use Only AI No. Note: Incomplete or Illegible Applications Will Not Be Processed. Ck/Voucher Elec Transfer No. Amt Received: I. Type of Notification: (check one) Postmark Date: Original Revised Canceled Additional Annual (Maintenance) II. Type of Operation: (check one) DEMO EMERGENCY ADVF No. RENO ORDERED NEGATIVE DECLARATION (Please note original ADVF no. if a rev.) No. ADVFs Reque.

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