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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 />NOTICE OF TERNUNATION <br />TO COMPLY WITH <br />ORDER NO. R5-2006-0054 <br />INDIVIDUAL DISCHARGER CONDITIONAL WAIVER OF <br />WASTE DISCHARGE REQUIREMENTS <br />FOR DISCHARGES FROM IRRIGATED LANDS <br />This document is only to be used for Individual Dischargers that have been issued a Notice of Applicability (NOA) by the <br />Executive Officer. Submission of this Notice of Termination constitutes official notification to the Central Valley Water <br />Board that the Individual Discharger identified below elects not be covered under Order No. R5-2006-0054, Individual <br />Discharger Conditional Waiver of Waste Discharge Requirements for Discharges from Irrigated Lands. <br />1. INDIVIDUAL DISCHARGER INFORMATION <br />Discharger Name: <br />Facility Name:r <br />Physical Address: <br />City/Locale: <br />County: <br />State: <br />Zip: <br />Mailing Address: <br />City/Locale: <br />County: <br />State: <br />Zip: <br />Telephone Number: <br />Facilities include lands where water is applied for the purpose of producing crops and includes commercial nurseries, nursery stock <br />production, managed wetlands and rice production. <br />2. LOCATION OF FACILITY <br />Assessor's Parcel #: Closest Surface Water: (e.g. Sacramento River) <br />Township/Range/Section: <br />T R 5 B&M <br />3. CERTIFICATION <br />I certify under penalty of law that (1) I am not required to be covered under the Conditional Waiver of <br />Waste Discharge Requirements For Discharges From Irrigated Lands Within The Central Valley Region, and (2) <br />this document and all attachments were prepared under my direction or supervision in accordance with a system <br />designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my <br />inquiry of the person or 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, accurate, and complete. I <br />am aware that there are significant penalties for submitting false information, including the possibility of fine and <br />imprisonment for knowing violations. I also understand that submittal of this Notice of Termination does not <br />release a facility from liability for any violations of the Conditional Waiver. <br />Print Name: Title: <br />Signature: Date: <br />