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L Page 6 <br /> � <br /> CALIFORNIA ENVIRONMENTAL State of California �e4Ae`t <br /> PROTECTION AGENCY <br /> Regional Water Quality Control Board <br /> "=. <br /> <%� J �ij� , " <br /> APPLICATION/REPORT OF WASTE DISCHARGE <br /> GENERAL INFORMATION FORM FOR <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT -" <br /> 'LlFOP"'a <br /> II. TYPE OF DISCHARGE <br /> Check Tvpe of Discharge(s) Described in this Application (A or B): <br /> A.WASTE DISCHARGE TO LAND ❑ B.WASTE DISCHARGE TO SURFACE WATER <br /> Check all that appy: <br /> ❑ Domestic/Municipal Wastewater ❑ Ail or A uacultural Wastewater <br /> Treatment and Disposal F-1Animalq <br /> 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: cleanup of Petroleum Fuel Pollution-General Order# <br /> 03-0044 <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: 085-310-11Facility:38 .0244°N Facility:121 . 2564°W <br /> Discharge Point: 0 8 5-310-11 Discharge Point:I38 .0246O N Discharge Point•.121 . 2 5 61 bW <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.San Joaquin County Environmental Health Department <br /> Has a public agency determined that the proposed project is exempt from CEQA? ER Yes [] No <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 ExemptionlAsencv: Title 14 CCR Section 15308/Regional Board <br /> Has a "Notice of Determination" been flied under CEQA? 0 Yes ❑ No <br /> If Yes, enclose a cop), of the CEQA document, Environmental Impact Report, or Negative Declaration. If no, identifv the <br /> expected type of CEQA document and expected date of completion. <br /> Expected CEQA Documents: <br /> ❑ EIR XA Negative Declaration Expected CEQA Completion Date: <br />