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CALIFORNIA ENVIRONMENTAL ` page 7 <br /> PROTECTION AGENCY State Of California <br /> Regional Water Quality Control Board APPLICATION/REPORT OF WASTE DISCHARGEGENERAL la <br /> N FORM FOR <br /> WASTE DISCHARGE REQUREMENTOR NPES PERMIT <br /> VI. OTHER REQUIRED INFORMATION <br /> Frovide a COMPLETE characterization of your discharge. A complete characterization includes, <br /> t limited to, design and actual flows, a list of constituents and the discharge concentration of eachnt,a list of other appropriate waste discharge characteristics, a descriptionand schematic drawingtment processes, a description of any Best Management Practices(BMPS)used, and a descriptional 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 /> You will <br /> notified <br /> tative of the RWQCB within 30 <br /> ays of <br /> application eis complete or ifptherenis additional information you must submit to receipt <br /> eoyouapplication. <br /> Applfcation/Report of WastetDis charge,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: <br /> Title: <br /> Signature: <br /> Date: <br /> FOR OFFICE USE ONLY <br /> Date Form 200 Received: Letter to Dischar ear: <br /> g Fee Amount Received: Check p: <br /> eocm 20,1/9w <br />