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FRpi' Ground Ze o Ano l y S I F-404E NO. t 204 WE) Fa iep. 26 2273 Z3:Z1PM F& <br /> � f <br /> Page 7 <br /> CAi 17'G'WMA SA`=0X?K pTAL State c`Caf:fornia <br /> YPMZCI.MNAGsaCY Freg.ionalVlza .rQuaLltyCo..tlrolBoard <br /> APFLICATIONIREPORT OF WASTE DISCHARGE �a <br /> GENERAL INFORMATION FORM FOR :� o <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT <br /> VZ. OTHER.'REQLLRERP FORMATION <br /> Please provide a IrOM.'�ETl Characterization of yoir discharge. A complete characterization �nc'udes, <br /> but is not limited to,deaign grid actual flows,a li>t of constituents and tI c discharge concentration of each <br /> consfitt nt,2 IIsi of other appropriate Wast(:diSChargC ChartrctzsisdCS,a&Scription and scherai,tic drawing <br /> of all t:,-atment processes,a des=fptiou of any Best'.Vanagemen:Practices(3-NLPs)used,said a descn-prior <br /> of disposal methods. <br /> Also;ztcfudc a si's mag shvh:ng the Iocatiazi of the fazilary azd,if you,are submitr:rg bis appkation fora* <br /> N?DES pe=nt,id= fy the nrface timtcr to which you propose to disetaarae. Please try to limit your Laps <br /> to a scale of l-24,000(75 USGS Quadnngic)or a strt:-t reap,:f more appropriatc. <br /> VIL OTHER <br /> Attach additional sheets to expIain An;;respansss which need tiarifieation. List attachments with titles and dates bel"; <br /> - Sactirm Cs The. cuczent fad itg, pperatpr in not the Responsible <br /> Party. <br /> Yon wM be nmmed try it reptts`ntative of the RwoCB voitWr 10 days of racelpt of your oVpUcadon. The nedcr ww state it%sur <br /> appllcatlfm is rnrapleta or It Ihrn is additional In fcr.U.400 you roust submit x complete your.ppli:atlotOUTtirt of Waste nists±arRt <br /> rorsuBar to Xsisision T.ScsHor. 132,50 of the C•nllfarnla Water Code. <br /> VID. CERTIFICATION <br /> "1 eerely uudtr penalty of last that this docutoent,tnr3udi%a all seAmhments and surptement7i Infer-natton.-e"prepared under tsy++ <br /> dinedea ind rnptrrsrivn In aeeardzrtee.t'ith it sycrem dtzipn4d to auara that gaalmod per;onuel properly satherod and tvtJttate0 she <br /> infams$aa sabmttted. Lased Olt my lnqulry of the penox or persane'who mauape the system,or thole persons dire,tty rgpaasibfe for <br /> gathtKng the taformntica,the lntormation submitted is:to the[rest of My kho"Jedge and belief,tape,Apcnrste and sotaith-a. I am aware <br /> that entre are significant penaltles for submitting false informatlon, faeludinq the posstbilay of!ine tine imprtsonment." <br /> Pri:ttN.=. RAY , BA6-LJETo TLW. Pfi ;1Y 4 <br /> 0 3 <br /> POP OPPICE USE ONLY <br /> �srh FbM ZQD Aewlvei: Lerear W Dtsaha.yfert =—OL'"t k4CN.ed: CAocw uL <br />