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` Page 7 <br /> CALIFORNIA ENVIRONMENTAL State of California a6 uRoee c <br /> PROTECTION AGENCY Regional Water Quality Control Board <br /> � o <br /> APPLICATION/REPORT OF WASTE DISCHARGE o <br /> GENERAL INFORMATION FORM FOR <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT <br /> VI. OTHER REQUIRED INFORMATION <br /> Please provide a COMPLETE characterization of your discharge. A complete characterization includes, <br /> but is not limited to, design and actual flows, a list of constituents and the discharge concentration of each <br /> constituent,a list of other appropriate waste discharge characteristics, a description and schematic drawing <br /> of all treatment processes, a description of any Best Management Practices (BMPs)used,and a description <br /> I of disposal methods. <br /> Also include a site map showing the location of the facility and, if you are submitting this application for an <br /> NPDES permit, identify the surface water to which you propose to discharge. Please try to limit your maps <br /> to a scale of 1:24,000 (7.5' USGS Quadrangle)or a street map, if more appropriate. <br /> VII. OTHER <br /> Attach additional sheets to explain any responses which need clarification. List attachments with titles and dates below: <br /> Jf,.. <br /> You will be notife by a representative of the RWQCB within 30 days of receipt of your application. The notice will state if your <br /> application is complete or if there is additional information you must submit to complete your Application/Report of Waste Discharge, <br /> pursuant to Division 7,Section 13260 of the California Water Code. <br /> VIII. CERTIFICATION <br /> "I certify under penalty of law that this document, including all attachments and supplemental information, were prepared under my <br /> direction and supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the <br /> information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for <br /> gathering the information,the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware <br /> that there are significant penalties for submitting false information, including the possibility of fine and im " <br /> prisonment. <br /> Print N u O-t1 Q Title: C e-s'% n "Ies- <br /> Signature <br /> Date: <br /> f <br /> I <br /> I <br /> FOR OFFICE USE ONLY <br /> r� LetDete Form 200 Received: <br /> ter to Discharger: Fee Amount Received: Check t1: <br /> Po-20016!971 <br />