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,1� 4 <br /> Page 6 <br /> CALIFORNIA ENVIRONMENTAL State of California <br /> PROTECTION AGENCY Regional Water Quality Control Board <br /> APPLICATION/REPORT OF WASTE DISCHARGE `'i, �Cm <br /> o <br /> GENERAL INFORMATION FORM FOR <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT <br /> II. TYPE OF DISCHARGE <br /> Check Type of Discharge(s)Described in this Application(A or B): <br /> ZA.WASTE DISCHARGE TO LAND ❑ B.WASTE DISCHARGE TO SURFACE WATER <br /> Check all that apply: <br /> ❑ Domestic/Municipal Wastewater ❑ Animal or Aquacultural Wastewater <br /> Treatment and Disposal ❑ Animal Waste Solids <br /> ❑ Cooling Water ❑ Land Treatment Unit ❑ Biosolids/Residual <br /> ❑ Mining ❑ Dredge Material Disposal ❑ Hazardous Waste (see instructions) <br /> ❑ Waste Pile ❑ Surface Impoundment ❑ Landfill (see instructions) <br /> ❑ Wastewater Reclamation ❑ Industrial Process Wastewater ❑ Storm Water <br /> �Other, please describe: t>Zas-Venc ew 1`rom Sc",%� � r•t_-s1n ea�e�wlDles 4 RQ�Aua4 301�S <br /> - -- - - -- <br /> F <br /> 1 <br /> III. LOCATION OF THE FACILITY <br /> Describe the physical location of the facility. <br /> 1. Assessor's Parcel Number(s) 2. Latitude 3. Longitude <br /> Facility: 01- 2-% - O 1(r Facility: 37.'g 1'I Facility: '- l21 .0 y <br /> 2. <br /> Discharge Point: Z o 3--z -O 1 U Discharge Point: '3-7, $1$ Discharge Point: i Z 1 ,ORS <br /> IV. REASON FOR FILING <br /> New Discharge or Facility ❑Changes in Ownership/Operator(see instructions) <br /> ❑ Change in Design or Operation ❑Waste Discharge Requirements Update or NPDES'Permit Reissuance <br /> ❑ Change in Quantity/Type of Discharge ❑Other: <br /> V.CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) <br /> Name of Lead Agency: -. <br /> Scar, �a�<�ca-•1 C.au..:. _ _. e.Iro ,MAk--} _..._ <br /> Has a public agency determined that the proposed project is exempt from CEQA? ❑Yes [�JINo <br /> If Yes,state the basis for the exemption and the name of the agency supplying the exemption on the line below. <br /> Basis for Exemption/Agency: <br /> Has a "Notice of Determination" been filed under CEQA? ❑ Yes Q'No <br /> If Yes, enclose a copy of the CEQA document,Environmental Impact Report, or Negative Declaration. If no, identify the <br /> expected type of CEQA document and expected date of completion. i'1,L5 . Ox c �a��u, flan�sutl2d <br /> Expected CEQA Documents: <br /> ❑ EIR ❑ Negative Declaration Expected CEQA Completion Date: <br /> Form 20016/971 <br />