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• <br />ATTACHMENT B <br />ORDER NO. R5-2006-0054 <br />INDIVIDUAL DISCHARGER CONDITIONAL WAIVER OF <br />WASTE DISCHARGE REQUIREMENTS <br />FOR DISCHARGES FROM IRRIGATED LANDS <br />4. ADDITIONAL INFORMATION <br />Please attach the following information to this NOI: <br />1. A site map, which shows the boundaries of the individual Discharger's farm/facility and identifies surface <br />watercourses within 1,000 feet of the farm. <br />2. Use the space below, or attach additional sheets, to explain any response that needs clarification. <br />5. CERTIFICATION <br />I certify under penalty of law that this document and all attachments were prepared under my <br />direction or supervision in accordance with a system designed to assure that qualified personnel <br />properly gather and evaluate the information submitted. Based on my inquiry of the person or <br />persons who manage the system, or those persons directly responsible for gathering the <br />information, the information submitted is, to the best of my knowledge and belief, true, <br />accurate, and complete. I am aware that there are significant penalties for submitting false <br />information, including the possibility of fine and imprisonment for knowing violations. <br />Print Name: Title: <br />Signature: Date: <br />-8- <br />