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FROM FAX NO. :2099315186 J 108 2003 09:36AM P3 <br /> CALIB' RSIA R2�RTAZi P8$96 <br /> 1 PR07 Qt]TIOA ACMCV Slateof Calif n-da <br /> Regional WaterQualityContmlBoard <br /> APPLICATION/REPORT OF WASTE DISCHARGE' <br /> GENERAL INFORMATION FORM FOR m <br /> ` <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT LVTWE � <br /> Check Type of Dlscharge(s)Described is this Aca ion(AD$ C AI�GE <br /> Pp <br /> A.WASTR DISCHARGE TO LAND <br /> Q B.WASTE DISCHARGE TO SURFACE <br /> • WATER <br /> Check all that Upply; <br /> Domestic/Munfeipai Wastewater <br /> Treatment and Dtsposa] ❑ ,Animal Waste Solids Q Animal or Aquacnitura] Wastevyatar <br /> C Cooling Water ❑ Land Treatment Unit <br /> d Mining ❑ BiosolicisfResidual <br /> © Waste pile ❑ Dredge Materiai Disposal El Hazardous Waste (see inatroctiogs) <br /> ❑ Surface Impoundment �] Landfill (see instructions) <br /> Wastewater Reclamation radustrial Process ocess Wastewater Q Storm Water <br /> ❑ Other, please describe: <br /> ' III, LOCATION OF TRE FACILIry 1 <br /> Describe the physical iocdtion of the facility. <br /> r <br /> I. Assessor's Parcel Number(s) 2. —� <br /> Faciuty; Latitude 3. Longitude <br /> Discharge point; Facility: Bacllity: <br /> Discharge Palma lalschnrge point: <br /> IV, REASON FOR FII,�NO <br /> FEI <br /> Discharge or Facility ❑Changes in Ownembip/operator(see instructions) T <br /> ge in De�Sign or OperationWaste Discharge Requirements pdate or N'PDFS Permit pei.9suace <br /> ge in QuandVrypo of Discharge P40ther: 9!,�(L%� Ih <br /> a <br /> V. CALIFORNIA ENVXRONMENTAL QUALITY A �~ <br /> CT(CE <br /> Name of Lead Agency; <br /> -Hi's a public agency determined that the proposed project is exempt Prom CEQA? 1 <br /> u Yes,state the basis for the exemption and the name oP the d enc au 1 ❑Yes ❑ No <br /> Basis far Exemption/Agency; E Y Pp ging the ex <br /> on the line below, <br /> Has a "Notice of Determinatim"been filed Under CEQA? es <br /> Ir Yes, enclose a copy ar the CEQA document,Lnvironmental xmpeCt�port,ar Negative IP no,identify the <br /> exPceted type or CEQA document and expected Bats of completion. <br /> Expected CEQA Documents.- <br /> ' <br /> ❑ F,IR NegaUva Declaration <br /> >=xpected <br /> fie,.400 r.i#ri GIiQA Campletian Date: <br />