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� 7 Page 6 CALIFORNIA ENVIRONIKEYTAL State ofCalEorn:il ego �cEs PROTECTION AGENCY Regional Water Quality Control$oard APPLICATIONIREPORT OF WASTE DISCHARGE o GENERAL INFORMATION FORM FOR "d WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT 4LiFOft NSP II. TYPE OF DISCHARGE Check Type of Discharge(s) Described in this Application (A or S): Q A. WASTE DISCHARGE TO LAND ❑ B.WASTE DISCHARGE TO SURFACE WATER Check all that apply: ❑ Domestic/Municipal Wastewater ❑ Animal A uacultural Wastewater € Treatment and Disposal [7 Animal Waste Solids or q ❑ Cooling Water ❑ Land Treatment Unit ❑ BiosolidsiResidual ❑ Mining ❑ Dredge Material Disposal ❑ Hazardous Waste (see instntctions) ❑ Waste Pile ❑ Surface Impoundment ❑ Landfill (see instntctions) ® Wastewater Reclamation � Industrial Process Wastewater ® Storm Water ❑ Other, please describe: III. LOCATION OF THE FACILITY Describe the physical location of the facility. 1. Assessor's Parcel Number(s) 2. Latitudeo 3. Longitude Facility: 011-150-12 Facility: 38 9} N Facility: 1210 24' W Discharge Point: 011-150-23 Discharge Point: Discharge Point: IV. REASON FOR FILING New Discharge or Facility ❑Changes in Ownership/Operator(see instructions) ❑ Change in Design or Operation ❑Waste Discharge Requirements Update or NPDES Permit Reissuance ❑ Change in Quantity/Type of Discharge ❑Other: V. CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) Name of Lead Agency: Sall Joaquin County Community Development Del2artment Has a public agency determined that the proposed project is exempt from CEQA? ❑ Yes ILI No If Yes,state the basis for the exemption and the name of the agency supplying the exemption on the line below. Basis for Exemption/Agency: Has a "\Notice of Determination" been Bled under CEQA? Yes ❑ No If Yes, enclose a copy of the CEQA document, Environmental Impact Report, or Negative Declaration. If no, identify the expected type of CEQA document and expected date of completion. Expected CEQA Documents: ❑ EIR Negative Declaration Expected CEQA Completion Date: Fa^n'_09 f tiro?}