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A. V1. QUANTITY OFPRUB <br /> DAILY FLOW NT ON ROPOa O I I ^W44A66 <br /> DAILY I U. DESIGN PLOW IN Mp �d•� <br /> rN At6p�; I 6.1 <br /> C. <br /> :.01r1-.1P( <br /> pL10 WAeTE DISPOSAL 1 PAILT GYANTITtlIN?LAC[RY ANTI4r ®• ARRA IN WHICH SOIL WILL DR OI$TUR RED •gOTwl!1T[ A«rw <br /> e1TR (IN TONS OR - <br /> IC VARA$): I I LIN ACRES) <br /> V11. LOCATION OF POINT OF OtSPOSAL OR OPERATION — - L— -i - <br /> lOR$16N AND ATTACH MAP,SKETCH,OR LOCATION pN <br /> LIST DISTANCES on ME ARING <br /> AND 0IeTANCK FROM SECTION CORNER OR QUARTER CORNER,SECTION,TOWNSHIP,RANGE,13A8E AND MERIDIAN: <br /> V111. SOURCE Of WATER SUPPLYICN[CK•—__.-_—._-._.: ...-:_—•._.___- _. <br /> LL APPAGPR1w Trl <br /> A. F1 MUNICIPAL OR UTILITY SERVICE: B- E] INDIVIDUAL(Wells) <br /> C. n SURFACE SUPPLY: <br /> RAMS OP STR[AM,LAK[.SPRING. <br /> R/GNTS w10NT!P[wMIT OR LIC[N![f <br /> Riparian l J Appropriation j <br /> -- -- - _ <br /> .�.• <br /> X. ENVIRONMENTAL IMPACT REPORT jE1R). <br /> Has an EIR been prepared for this project? Yes ❑ No —If"Yes",please enclose a copy. <br /> If"No",will an EIR be prepared? Dyes No <br /> Will a negative declaration be prepared? ® Yes ❑ No <br /> It"Yes please answer the P <br /> wN <br /> following: '— -- _ <br /> D W;;11e <br /> I" w[Pww[TN[w[ow rlv[D[CLA RA TIONT APPN Ow.owTA Or OMPLlT <br /> ton <br /> CERTIFICATION <br /> ION <br /> I hereby certify under penalty of perjury that the information provided in this application and in any attach• <br /> ments is true and accurate to the best of my knowledge. <br /> e/ON ATURE OF OWq/RR OP ?AGILITY —'---'--" - <br /> $16NAT411E OP OPERATOR OF FACILITY <br /> •_-_ .. <br /> PRINT'[O ON TT►rY NwMr ........ <br /> "'-------- <br /> -__— ..._.. <br /> ' Ow7t TIT4e ._.. ..... <br /> LIST TITLE OF ANV ATTACHMRNTe: � --� �---_" <br /> You will be notified of the correctness of filing fee and submittal of any additional information deemed necessary to complete your Report of Waste <br /> Discharge pursuant to Division 7, Section 13250 of the State Water Code,or to Complete your permit application pursuant to Government Code <br /> Section 66796.30 and Health and Safety Code Section 25200. <br />