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• • Page6 <br /> CALIFORNIA ENVIRONMENTAL State of California ,o races <br /> PROTECTION AGENCY <br /> Regional Water Quality Controllc Af <br /> APPLICATION/REPORT OF WASTETE DISCHARGE <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 or B): <br /> ✓❑ A.WASTE DISCHARGE TO LAND F-1 B.WASTE DISCHARGE TO SURFACE WATER <br /> Check all that apply: <br /> ❑ Domestic/Municipal Wastewater ❑ Animal orAquacultural Wastewater <br /> I 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 <br /> ❑ Industrial Process Wastewater ❑ Storm Water <br /> ❑✓ Other, please describe: <br /> N <br /> ' III. LOCATION OF THE FACILITY <br /> Describe the physical location of the facility. <br /> 1 1. Assessor's Parcel Number(s) [2.,J Latitude3. Longitude <br /> Facility: cility: 37:52:58N Facility: 121:16:43W <br /> Discharge Point: 19321003 scharge 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 ❑Other: <br /> V. CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) <br /> Name of Lead Agency: Not applicable <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: <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 /> ❑ FIR ❑ Negative Declaration Expected CEQA Completion Date: Not applicable <br /> ,o�m zoo psis,: <br />