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Page 6 <br /> cALn+oRNIA ENvIROPNENTAL State of California <br /> PROTECTION AGENCY Regional Water Quality Control Board S <br /> APPLICATIONIREPORT OF WASTE DISCHARGE r <br /> GENERAL INFORMATION FORM FOR `• <br /> WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT <br /> II. TYPE OF DISCHARGE <br /> Check Type of Discharge(s)Described in this Application (A gr B): <br /> M A.WASTE DISCHARGE TO LAND ❑ B.WASTE DISCHARGE TO SURFACE WATER <br /> Check all that apply: <br /> Domestic/Municipal Wastewater❑ ElAnimal or Aquacultural Wastewater Treatment and Disposal ❑ Animal Waste Solids <br /> ❑ Cooling Water F-1LandTreatment Unit E] 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: Disposal of brine waste and other salt-containin Process <br /> water in onsite class 2 in'ection well o at under UIC Permit CA 920000 <br /> 01. <br /> III. LOCATION OF THE FACILITY <br /> Describe the physical location of the facility. <br /> 1. Assessor's Parcel Number(s) 2. Latitude 3. Longitude <br /> Facility: 183-140-08 Facility: 37` 55' 25" Facility: 121° 5' 30" <br /> Discharge Point: Discharge Point: Discharge Point: <br /> IV. REASON FOR FILING <br /> ❑ New Discharge or Facility ❑Changes in Ownership/Operator(see instructions) <br /> ❑ Change in Design or Operation ❑Waste Discharge Requirements Update or NPDES Permit Reissuance <br /> ❑ Change in Quantity/Type of Discharge laother, No iprocess water, wastewater, or stornsvater <br /> by Simmer-Fall 2005. <br /> V. CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) <br /> Name of Lead Agency: <br /> Has a public agency determined that the proposed project is exempt from CEQA? ®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: vrr)n ung ^'__ .., R5-2004-0 157, Finding No 34 <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 ❑ Negative Declaration Expected CEQA Completion Date: <br /> rom zoo(cisi) <br />