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<br /> „ ,..r p.~r <br /> E. Specify the amount of time requested for the variance and the reasons for such a time <br /> period. Note that the Director cannot issue a variance for a period exceeding five years (if <br /> additional space is required, please include the information on a separate attachment and <br /> Label ("Attachment E-7'). <br /> SEE A~TT?.GrAM@aT E-\ <br /> F. Submit any adtlitional information which will support this application for a variance (i.e., <br /> statements, plans, area maps, histories, etc., and label'Attachment F-1"). <br /> S Ee p.'trr.cA rnC.JZ'f F- <br /> III. CERTIFICATION: <br /> Keith Kato Executive Dirctor <br /> I, , <br /> (print name) (pnnt title) <br /> certify that I have knowledge of the facts herein set forth and that the same are true and correct to <br /> the best of my knowledge and belief. _ <br /> Signature: t/1.,1~, <br /> f'/~',t,~ (//Ly/ <br /> Date: z~zi~~nns <br /> DO NOT WRITE BEyL-OW -FOR AGENC~Y/U~S'E~ONLY <br /> IV. Date App~icationreceived:_ ~}in~/\~~/~12.5r v'.".'~ <br /> V. Application No.: ¦ ' • - I <br /> VI. Docket No.: O15 ~ AyAW V `r <br /> VII. Received by: ~~77.tp~,"~^~1~`rl ,/1 <br /> VIII. Filing Fee ($300.00) check date: ~~L C/ ' IJ~~iJ Check tf ~ y~ _ <br /> IX. Department of Health Receipt tt: I v ~O <br /> X. Derision on Application (including date): <br /> XI. Dale of PW>lic Hearing: <br /> APp~~ea6on for Variarce.tloc vww feWUary 2005 Page 3 of 3 <br /> <br />