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Page 6 <br /> CALIFORNIA ENVIRONMENTAL State of California �5 J�CES C <br /> PROTECTION AGENCY Regional Water Quality Control Board �Pe .��.. 0 <br /> APPLICATION/REPORT OF WASTE DISCHARGE m <br /> GENERAL INFORMATION FORM FOR _ <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT Ys <br /> • C'��IfOHNP <br /> II. TYPE OF DISCHARGE <br /> Check Type of Discharge(s)Described in this Application(A or B): <br /> © A.WASTE DISCHARGE TO LAND ❑ B.WASTE DISCHARGE TO SURFACE WATER <br /> Check all that apply: <br /> ❑ Domestic/Municipal Wastewater ❑ Animal or Aquacultural Wastewater <br /> Treatment and Disposal ❑ Animal Waste Solids <br /> ❑ Cooling Water ❑ Land Treatment Unit ❑ Biosolids/Residual <br /> ❑ Mining ❑ Dredge Material Disposal ❑ Hazardous Waste (see instructions) <br /> ❑ Waste Pile ❑ Surface Impoundment ❑ Landfill (see instructions) <br /> ❑ Wastewater Reclamation ❑ Industrial Process Wastewater ❑ Storm Water <br /> ❑ Other, please describe: <br /> III. LOCATION OF THE FACILITY <br /> Describe the physical location of the facility. <br /> 1. Assessor's Parcel Number(s) 2. Latitude 3 ti� (4( 3. Longitude 12-1 .3,7 <br /> Facility: O 11 - o,50 -UO Facility: Facility: <br /> Discharge Point: Discharge Point: Discharge Point: <br /> L 243 Ai, ZuN RDA6 <br /> IV. REASON FOR FILING <br /> ❑ New Discharge or Facility ❑Changes in Ownership/Operator(see instructions) <br /> Q Change in Design or Operation ❑Waste Discharge Requirements Update or NPDES Permit Reissuance <br /> Change in Quantity/Type of Discharge ❑Other: <br /> V. CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) <br /> Name of Lead Agency: SAN -Ti2•AQY I lJ &')U NTt/ ���n?uN I r y b�(�<LyP/y7Ei✓T (fit e/ <br /> Has a public agency determined that the proposed project is exempt from CEQA? 0 Yes ❑ No <br /> If Yes, state the basis for the exemption and the name of the agency supplying the exemption on the line below. <br /> Basis for Exemption/Agency: <br /> Has a "Notice of Determination" been filed under CEQA? ❑ Yes ❑ No <br /> If Yes, enclose a copy of the CEQA document, Environmental Impact Report,or Negative Declaration. If no,identify the <br /> expected type of CEQA document and expected date of completion. <br /> Expected CEQA Documents: <br /> ❑ EIR El Negative Declaration Expected CEQA Completion Date: <br /> Form 200(6/97) <br /> r <br />