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R2g4T <br /> PRZYoCALEMRWA o7flll�irpt, Stabs of California <br /> Regiflnai Water QualityCor►trol Beard <br /> APPLICATIONIREPORT OF WASTE DISCHARGE <br /> GENERAL INFORTIONRM FOR <br /> WASTE DISCHARGE REQUIREMENTS OIC NP E5 P � <br /> ERMIT ' <br /> VI. OTHER REQUIRED INFORMATION <br /> Please provide a COMPLETE characterization of your discharge. A complete characterization includes, <br /> but is not limited to,design and actual flows,a list of constituents and the discharge concentration of each <br /> constituent,a list of Other appropriate waste discharge characteristics,adescription and schematic drawing <br /> Of all treatment processes,a description of any 13est Management Practices(BMPs use and a <br /> description <br /> of disposalP <br /> me <br /> . tlrods. <br /> Also include a site Map showing the Iocation of the facility and,if you are submitting tills application for ars <br /> NPDES permit,identify the surface water to which you propose to discharge. please try to limit your maps <br /> to a scale of 1:24,000 (7.5'USGS Quadrangle)or a street map,if more appropriate. <br /> i <br /> VII. OTHER <br /> Attach additional sheets to explain any responses which need clariticatian. List attachments with titles and dates below; <br /> You will ba notllied by a representotlya of the RWQCB within 30 days of receipt of your application The native will state if your F <br /> Application Is complete or if there is additional loformntion you roust subsalt to complete your Application/Repart of Waste Discharge, i <br /> pursuant to Division 978ectlon 13260 of the California Water Code. <br /> VHI. CERTIFICATION <br /> "Ice-Ally,under penalty of law that this document, Including all attachments And supplemental information, were prepared under my <br /> direction and supervlslon In accordance with it system designed to assure that quollfiad personnel properly gathered and evaluated the <br /> Information submitted, Based on my inquiry of the person or persons who monde the system,or those persons directly responsible for <br /> gathering the In(armation,the information submItted is,to the best of my knowledge and belief,true,accurate,and complete. I am aware <br /> that there are Ignificaji penalties for submitting false information, including the possibility of Rine and imprisonment." <br /> Printivamet n �nDnt • oris: �+�S1r�c�� <br /> sigma Z <br /> i <br /> FOR OFFICE VSE ONLY <br /> !i <br /> ate Form 200 Re4eivad. Letter to Desch--ere Pee Amount lteeelvedc Check i!: <br /> ►01n74eff1l71 �7 d ■ <br /> sTd WdOT:t70 P-00Z 60 '6n1j 981ST2660Z: 'ON Xtid <br />