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SECTION IV. ADDRESS FOR CORRESPONDENCE IL1_1 Facility Operator Mailing Address (Section II) ]%�l Facility Mailing Address (Section 111. B.) 11 Both SECTION V. BILLING ADDRESS INFORMATION SEND BILL TO: ( ]Facility Operator Mailing Address (Section 11) (]Facility Mailing Address (Section III, B.) ( ]Other (enter information below) Name: Phone Mailing Address: 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 City Slate: Zip Code. Contact Person: I I I I I I I I I I I! I I I I I I I I I I I I I I I I I I I SECTION VI. RECEIVING WATER INFORMATION Your facility's storm water discharges flow: (check one) ( ) Directly Name of receiving water OR K Indirectly to waters of the United States. (river, take, stream, ocean, etc.) SECTION VII. IMPLEMENTATION OF PERMIT REQUIREMENTS A. STORM WATER POLLUTION PREVENTION PLAN (SWPPP) (check one) ( ) A SWPPP has been prepared for this facility and is available for review. k'A SWPPP will be prepared and ready for review by (enter date): B. MONITORING PROGRAM (check one) I I A Monitoring Program has been prepared for this facility and is available for review. / Q,dA Monitoring Program will be prepared and ready for review by (enter date): jQ/_/�. C. PERMIT COMPLIANCE RESPONSIBILITY Has a person been assigned responsibility for: 1. Inspecting the facility throughout the year to identify any potential pollution preblP.ms?............................................................. ✓YES NO 2. Collecting storm water samples and having them analyzed?............................................................. ............... ..........................-7YES _NO 3. Preparing and submitting an annual report by July 1 of each year?............................................................................................�--YES ,NO d. Eliminating discharges other than storm water (such as equipment or vehicle wash -water) into the storm drain? ...................... ✓ YES NO SECTION VI11. REGULATORY STATUS (Go to Section 1X i1 not applicable) p A. WASTE DISCHARGE REQUIREMENT ORDER NUMBER: I I I 1 1 1 11 B. NPDEE PERMIT CA I I I I I I I I SECTION IX. SITE MAP I HAVE ENCLOSED A SITE MAP YES(Y A new NOI submitted without a site map will b: rejected. SECTION X. CERTIFICATION "I certify under penalty of law that this document and all attachments were prepared under my direction a id supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information sibmitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. In addition, I certify that the provisions of the permit, including the development and implementation of a Storm Water Pollution Prevention Plan and a Monitoring Program Plan, will be complied with." Printed Name: Signature Title: Cate