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..i CALIFORNIA ENVIRONMENTAL Page5 PROTECTION AGENCY State of California Regional Water Quality Control Board APPLICATION/REPORT OF WASTE DISCHARGE a �� GENERAL INFORMATION FORM FOR WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT A. Facilit I• FACILITY INFORMATION Luse.: :y: County: Sede: ntact Person: Telephone Number: B. Facility Owner: Name: Owner Type (Check One) 1. ❑ lydividual 2. Corporation Address: 3. oover�eatal 4. partnership Agency City: grate: Zip Code: Contact Person: Telephone Number: Federal Tax It: C. Facility Operator (The agency or business, not the person : Name: Operator Type (Check One) I. ❑ lndiviaca1 2. Corporation Address: 3. Governmental 4. Partnership City: Agency State: Zip Code: 5. other: Contact Person: Telephone Kosher: D. Owner of the Land: Name: O ar Type (check One) 1' IMividv� 2. Corporation Adareee: 3. Gove mrmntal 4. Partnership City: Agency State: Zip code: S. ❑ Other: Contact Person: Telephone Number: E. Address Where Legal Notice May Be Served: Adareee: City: Stabs: Zip Code: Contact person: Telephone Number: EAddr... Billin Address: : aty: Stara: ZiCode: ontact Person: Telephone xnmiher: earm xoa is/svl