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Page 4 CALIFORNIA ENVIRONMENTAL State of California 55�UR -8 C PROTECTION AGENCY Regional Water Quality Control Board APPLICATION/REPORT OF WASTE DISCHARGE �` �m GENERAL INFORMATION FORM FOR WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT *s r'CIFCN N.P V. CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) It should be emphasized that communication with the appropriate RWQCB staff is vital before starting the CEQA documentation, and is recommended before completing this application. There are Basin Plan issues which may complicate the CEQA effort, and RWQCB staff may be able to help in providing the needed information to complete the CEQA documentation. Name the Lead Agency responsible for completion of CEQA requirements for the project, i.e., completion and certification of CEQA documentation. Check YES or NO. Has a public agency determined that the proposed project is exempt from CEQA? If the answer is YES, state the basis for the exemption and the name of the agency supplying the exemption on the space provided. (Remember that, if extra space is needed, use an extra sheet of paper, but be sure to indicate the attached sheet under Section VII. Other.) Check YES or NO. Has the "Notice of Determination"been filed under CEQA? If YES, give the date the notice was filed and enclose a copy of the Notice of Determination and the Initial Study, Environmental Impact Report, or Negative Declaration. If NO, check the box of the expected type of CEQA document for this project, and include the expected date of completion using the timelines given under CEQA. The date of completion should be taken as the date that the Notice of Determination will be submitted. (If not known, write "Unknown") OTHER REQUIRED INFORMATION To be approved, your application MUST include a COMPLETE characterization of the discharge. If the characterization is found to be incomplete, RWQCB staff will contact you and request that additional specific information be submitted. This application MUST be accompanied by a site map. A USGS 7.5' Quadrangle map or a street map, if more appropriate, is sufficient for most applications. V_IL OTHER If any of the answers on your application form need further explanation, attach a separate sheet. Please list any attachments with the titles and dates on the space provided. VIII. CERTIFICATION Certification by the owner of the facility or the operator of the facility, if the operator is different from the owner, is required. The appropriate person must sign the application form. Acceptable signatures are: 1. for a corporation, a principal executive officer of at least the level of senior vice-president; 2. for a partnership or individual (sole proprietorship), a general partner or the proprietor; 3. for a governmental or public agency, either a principal executive officer or ranking elected/appointed official. DISCHARGE SPECIFIC INFORMATION In most cases, a request to supply additional discharge specific information will be sent to you by a representative of the RWQCB. If the RWQCB determines that additional discharge specific information is not needed to process your applica- tion, you will be so notified. Form 200(6/97)