SITE INFORMATION AND CORRESPONDENCE

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• • Page 7 CALIFORNIA ENVIRONMENTAL State of California Peso"races co PROTECTION AGENCY Regional Water Quality Control Board APPLICATION/REPORT OF WASTE DISCHARGE GENERAL INFORMATION FORM FOR WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT a „ VI. OTHER REQUIRED INFORMATION Please provide a COMPLETE characterization of your discharge. A complete characterization includes, but is not limited to, design and actual flows, a list of constituents and the discharge concentration of each constituent, a list of other appropriate waste discharge characteristics,a description and schematic drawing of all treatment processes,a description of any Best Management Practices(BMPs)used,and a description of disposal methods. Also include a site map showing the location of the facility and, if you are submitting this application for an NPDES permit, identify the surface water to which you propose to discharge. Please try to limit your maps to a scale of 1:24,000 (7.5' USGS Quadrangle) or a street map, if more appropriate. VII. OTHER Attach additional sheets to explain any responses which need clarification. List attachments with titles anti dates below: You will be notified by a representative of the RWQCB within 30 days of receipt of your application. The notice will state if your application is complete or if there is additional information you must submit to complete your Application/Report of Waste Discharge, pursuant to Division 7, Section 13260 of the California Water Code. VIII. CERTIFICATION "I certify under penalty of law that this document, including all attachments and supplemental information, were prepared under my direction and supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment." Print Name: Title: Signature: Date: FOR OFFICE USE ONLY Date Form 200 Received: Letter to Discharger: Fee Amount Received: Check N: F..200(6/90)