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• • Page6 CALIFORNIA ENVIRONMENTAL State of California ,o races PROTECTION AGENCY Regional Water Quality Controllc Af APPLICATION/REPORT OF WASTETE DISCHARGE GENERAL INFORMATION FORM FOR WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT II. TYPE OF DISCHARGE ' Check Type of Discharge(s)Described in this Application(A or B): ✓❑ A.WASTE DISCHARGE TO LAND F-1 B.WASTE DISCHARGE TO SURFACE WATER Check all that apply: ❑ Domestic/Municipal Wastewater ❑ Animal orAquacultural Wastewater I Treatment and Disposal ❑ Animal Waste Solids ❑ Cooling Water ❑ Land Treatment Unit ❑ Biosolids/Residual ❑ Mining ❑ Dredge Material Disposal ❑ Hazardous Waste (see instructions) ❑ Waste Pile ❑ Surface Impoundment ❑ Landfill (see instructions) ❑ Wastewater Reclamation ❑ Industrial Process Wastewater ❑ Storm Water ❑✓ Other, please describe: N ' III. LOCATION OF THE FACILITY Describe the physical location of the facility. 1 1. Assessor's Parcel Number(s) [2.,J Latitude3. Longitude Facility: cility: 37:52:58N Facility: 121:16:43W Discharge Point: 19321003 scharge Point: Discharge Point: IV. REASON FOR FILING ❑✓ New Discharge or Facility ❑Changes in Ownership/Operator(see instructions) ❑ Change in Design or Operation ❑Waste Discharge Requirements Update or NPDES Permit Reissuance ❑ Change in Quantity/Type of Discharge ❑Other: V. CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) Name of Lead Agency: Not applicable Has a public agency determined that the proposed project is exempt from CEQA? ❑Yes ✓❑ No If Yes,state the basis for the exemption and the name of the agency supplying the exemption on the line below. Basis for Exemption/Agency: Has a "Notice of Determination" been filed under CEQA? ❑ Yes ❑ No If Yes, enclose a copy of the CEQA document, Environmental Impact Report, or Negative Declaration. If no,identify the expected type of CEQA document and expected date of completion. Expected CEQA Documents: ❑ FIR ❑ Negative Declaration Expected CEQA Completion Date: Not applicable ,o�m zoo psis,: