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r Page 7 <br /> CALIFORNIA ENVIRONMENTAL State ofCahfotniaE5 ^c c <br /> PROTECTION AGENCY Regional Water QualityControl&)ard rP <br /> APPLICATION/REPORT OF WASTE DISCHARGE <br /> GENERAL INFORMATION FORM FOR <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT <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, a description and schematic drawing <br /> of all treatment processes, a description of any Best Management Practices(BMPs) used, and a description <br /> of disposal methods. <br /> Also include a site map showing the location of the facility and, if you are submitting this application for an <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 /> VII. OTHER <br /> Attach additional sheets to explain any responses which need clarification. List attachments with titles and dates below: <br /> E�o/iT O WASTE 015CHAiz4E <br /> yer1- 5u (7AB1117Y 510D,1, Nir2ATE 40ADi/✓4 -77-tt1>4 /YIANur2t MAnJ�14r�lkM� Pesti <br /> AP tz l `I 2 oc)4 <br /> You will be notified by a representative of the RWQCB within 30 days of receipt of your application. The notice will state if your <br /> application is complete or if there is additional information you must submit to complete your Application/Report of Waste Discharge, <br /> pursuant to Division 7,Section 13260 of the California Water Code. <br /> VIII. CERTIFICATION <br /> "I certify under penalty of law that this document,including all attachments and supplemental information, were prepared under my <br /> direction and supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the <br /> information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for <br /> gathering the information, the information submitted is,to the best of my knowledge and belief,true,accurate,and complete. I am aware <br /> that there are significant penalties for submitting false information, including the possibility of fine and imprisonment." <br /> Print Name: Title: <br /> Signature: Date: <br /> FOR OFFICE USE ONLY <br /> Date Form 200 Received: Letter to Discharger. Fee Amount Received: Check#: <br /> F-200(6/97) <br /> t• <br />