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ATTACHMENT <br /> TO WQ ORDER <br /> NO. 2003-0003-DWQ <br /> State Water Resources Control Board <br /> NOTICE OF TERMINATION <br /> TO COMPLY WITH THE TERMS OF WATER QUALITY ORDER NO. 2003-0003-DWQ <br /> STATEWIDE GENERAL WASTE DISCHARGE REQUIREMENTS <br /> FOR DISCHARGES TO LAND WITH A LOW THREAT TO WATER QUALITY <br /> WDID # <br /> I. Property Owner , <br /> Name <br /> Mailing Address <br /> City County State Zip Phone <br /> Contact Person <br /> IF Facility Owner <br /> Name <br /> Mailing Address <br /> City County State Zip Phone <br /> Contact Person <br /> Ill. Site Location <br /> Street(including address, if any) <br /> Nearest Cross Street(s) <br /> County: <br /> IV. CERTIFICATION <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction and <br /> supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the <br /> information submitted. Based on my inquiry of the person or persons who manage the system,or those persons <br /> directly responsible for gathering the information,the information submitted is,to the best of my knowledge and <br /> belief,true, accurate,and complete. I am aware that there are significant penalties for submitting false information, <br /> including the possibility of fine and imprisonment." , <br /> Signature of Facility Owner Title <br /> Printed or Typed Name Date <br /> Signature of Property Owner Title <br /> Printed or Typed Name - Date <br /> STATE USE ONLY <br /> WDID: Regions]Board Office: Dale NOT Received: Date NOT <br /> ❑❑ Processed: <br />