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Page 2 <br /> CALIFORNIA ENVIRONMENTAL State of California Pis;RHES�o <br /> PROTECTION AGENCY Regional Water Quality Control Board <br /> APPLICATION/REPORT OF WASTE DISCHARGE 3�, <br /> GENERAL INFORMATION FORM FOR <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT <br /> INSTRUCTIONS <br /> FOR COMPLETING THE APPLICATION/REPORT OF WASTE DISCHARGE <br /> GENERAL INFORMATION FORM FOR: <br /> WASTE DISCHARGE REQUIREMENTS/NPDES PERMIT <br /> If you have any questions on the completion of any part of the application, please contact your RWQCB representative. A map of <br /> RWQCB locations, addresses, and telephone numbers is located on the reverse side of the application cover. <br /> Z FACILITY INFORMATION <br /> You must provide the factual information listed below for ALL owners, operators, and locations and, where appropriate, for ALL <br /> general partners and lease holders. <br /> A. FACILITY: <br /> Legal name, physical address including the county, person to contact, and phone number at the facility. <br /> (NO P.O. Box numbers! If no address exists, use street and nearest cross street.) <br /> B. FACILITY OWNER: <br /> Legal owner, address, person to contact, and phone number. Also include the owner's Federal Tax Identification <br /> Number. <br /> OWNER TYPE: <br /> Check the appropriate Owner Type. The legal owner will be named in the WDRs/NPDES permit. <br /> C. FACILITY OPERATOR (The agency or business,not the person): <br /> If applicable, the name, address, person to contact, and telephone number for the facility operator. Check the <br /> appropriate Operator Type. If identical to B. above, enter "same as owner". <br /> D. OWNER OF THE LAND: <br /> Legal owner of the land(s) where the facility is located, address, person to contact, and phone number. Check the <br /> appropriate Owner Type. If identical to B. above, enter "same as owner". <br /> E. ADDRESS WHERE LEGAL NOTICE MAY BE SERVED: <br /> Address where legal notice may be served, person to contact, and phone number. If identical to B. above, enter <br /> "same as owner". <br /> F. BILLING ADDRESS <br /> fto Address where annual fee invoices should be sent, person to contact, and phone number. If identical to B. above, <br /> enter "same as owner". <br /> v <br /> Form 200(6/97) <br />