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CALl70FXUnM=XX=TAL Page a <br /> PRO'rliiC'1 al11GE11ey StweOfCalifortlia <br /> Re&otUd Water Quality C=Jrol Board <br /> APPLICATION/REPORT OF WASTE DISCHARGE ' <br /> GENERAL INFORMATION FORM FOR U � <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT Y ° <br /> XI. TYPE OF DISCHARGE <br /> Check Type of Discharge(s)Described in this Appllcatloo(A tr Ig): <br /> A.WASTE DISCHARGE TO LAND C] B.WASTE DISCHARGE TO SURFACE <br /> WATER <br /> Check all that apply.- <br /> Domestic/Municipal <br /> pply;Domestic/Municipal Wa9tewater <br /> Treatment and Disposal ❑ Animal Waste Solids ❑ Animal or Aquacultural Wastewater <br /> Cooling Water ❑ Land Treatment Unit ❑ Biosolids/Residual <br /> Q Mining ❑ Dredge Material Disposal ❑ Hazardous Waste (see instructions) <br /> ❑ Waste Pile ❑ Surfice Impoundment ❑ Landfill (see instructions) <br /> ❑ Wastewater Reclamation industrial Process Wastewater ❑ Storm Water <br /> ❑ Other, please deschbo: <br /> i <br /> TIL LOCATION OF THE FACILI'T'Y <br /> Describe the physical location of the facility. <br /> 1. Assessor's Parcel Number(s) Z. Latitude 3. L,pngitude l <br /> Facility: lracuity: ► Facliltyt 4 r 0Q w <br /> Discharge Point; Discharge Paint: B* �� .� Discharge Poinl: � � ! 01 W <br /> IV. REASON FOR FILING <br /> X-New Discharge or Facility ❑Changes in Ownership/Operator(set instructions) <br /> ❑ Change in Desigp or Operation ❑Waste Discharge Requirements pda(tto or <br /> NPDES Permit Reissuance <br /> ❑ Change in Quantity/Type of Discharge other: �f oca�I y Xf �� <br /> V. CALrPORNIA ENVIRONMENTAL QUALITY ACT (CEQA.) <br /> Name or Lead Agency: 5 UtA Cdwn�j C OMMV04v at <br /> Has a public agency determined that the proposed project is exempt from Cl; A? [DYes CKNo <br /> It Yes,state the basis for the exemption and the pnoto or the agency supplying the exemption on the line below. <br /> Basis for Exomptlon/Agency. <br /> Has a "Notice of Determination"been filed under CEQAT ❑ Yes CR No <br /> Lf Yoe, $nclose a copy of tho CEQA document,EnAroamentsl Impact Report,or Negative Declaration. If no,Identify the <br /> expected typo of CEQA document and expected date of completion. <br /> Expected CEQA Documetlts: <br /> ❑ EIA PVr Nagntive Declaration Expected CEQA Completion Date; f <br /> N+ne off l///.I <br /> bTd WdbT:tVo coot 6o .6nd 9eTST2660E: "ON XUJ <br />