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' • • Page <br /> CALIFORNIA ENVIRONMENTAL Slateof California <br /> ' PROTECTION AGENCY Regional Water Quality Control Board <br /> APPLICATION/REPORT OF WASTE DISCHARGE 3 m� ago <br /> GENERAL INFORMATION FORM FOR f <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 /> Q A.WASTE DISCHARGE TO LAND ❑ B.WASTE DISCHARGE TO SURFACE WATER <br /> ' *See "Other" below <br /> Check all that apply: <br /> ❑ Domestic/Municipal Wastewater ❑ Animal orAquacultural Wastewater <br /> Treatment and Disposal ❑ Animal Wase Solids <br /> ❑ Cooling Water El Land Treatment Unit ❑ Biosolids/Residual <br /> E3 Mining El Dredge Material Disposal ❑ Hazardous Waste (see instructions) <br /> ❑ Waste Pile ❑ Surface Impoundment ❑ Landfill (see instructions) <br /> ❑ Wastewater Reclamation ❑ Industrial Process Wastewater ❑ Storm Water <br /> ES Other, please describe: Irrigation with reclaimed water <br /> I <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: 209-11-31 Facility:37N 42' 42" Facility: 121W 31' 47" <br /> Discharge Point: Discharge Point: Discharge Point: <br /> —240-26 37N 42' 35" 121W 29' 07" <br /> 209-240-27 37N 42' 37" 121W 30' 24" <br /> 209-230=19 <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 Pemtit Reissuance <br /> (51 Change in Quantity/Type of Discharge []Other: Change in location of discharge <br /> V. CALIFORNIA ENVIRONMENTAL QUALITY ACT(CEQA) <br /> Name ofUadAgency: Regional Water Quality Control Board <br /> Has a public agency determined that the proposed project is exempt from CEQA? ❑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 Exemption/Agency: �� <br /> Has a "Notice of Determination" been filed under CEQA? ❑ Yes ED 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. <br /> Expected CEQA Documents: <br /> E] EIR ® Negative Declaration Expected CEQA Completion Date: <br /> F m 2M6/9]) <br />