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L 11 Facility OPerafor Mailing Address (Section H) 11 FaCility Mailing Add-ess (Section Ili, B.) 1_1 Both
<br />ION V. BILLING ADDRESS INFORMATION
<br />SEND BiLL TO I ]Facility Operator Mailing Address (Section fl) )Facility Mailing Address (Section 111, B) O_)lher (enter Information beiow)
<br />N Name,
<br />I j --I I I I_1 1
<br />Mailing Address
<br />city
<br />State. ZIP Code:
<br />Contact Person
<br />SECTION VI. RECEIVING WATER INFORMATION
<br />Your facility's storm water discharges flow: (check one) I I Directly OR
<br />Indirectly to waters of the United States
<br />Name of receiving water I I I I I I I I I I I I I___1 111 1
<br />(river, lake, stream, ocean. etc
<br />SECTION VII_ IMPLEMENTATION OF PERMIT REQUIREMENTS
<br />A STORM WATER Pa ILUTION PREVENTION PLAN (SINPPP) (c�,,ecp oric,i
<br />I
<br />I FICII I
<br />a eesa e , h ,, k
<br />"fly. s to',, water
<br />'g- flow:
<br />e e
<br />Name of ,,ing w
<br />S t"ea 0_
<br />etc)
<br />A S
<br />A 'S,)vPFIP has been prepared to,, this facility and is availabt v
<br />for reiew
<br />A SWPPP will be prepared and ready for review by (ef !er date)
<br />'OHITOR;NG PROGRAM (check one)
<br />00nitOring Program has been prepared for this facility and is available for review
<br />Monitoring Program will be prepared and ready for review by (enter date).
<br />'C PERMIT COMPLIANCE RESPONSIBILITY
<br />Has a person
<br />-son been assigned responsibility for.
<br />I Inspecting the facility throughout the year to identify any potential pollution p,obfems-;
<br />2 Collecting storm water samples and having them analyze.,-, --YES --NO
<br />YES NO
<br />3 Preparing and submitting an annual report by July I of eac'h year?_',
<br />. .. .... _—_YES_NO
<br />4 Eliminating discharges other than storm water (such as equtp,7iP_n,, or vehJcle wash-Walcr) into the storm drain? , . ..... .. —YES —NO
<br />SECTION VIII. SITE MAP
<br />I HAVE ENCLOSED A SITE MAP YESI I A now NOI submitted without a site map will be rejected.
<br />SECTION IX. CERTIFICATION
<br />certify under penalty of law that this document and all attachments were prepared under my direction and Supervision in accordance with a system
<br />designed to assure that qualified personnel properly gather and evaluate the information submitted Based on my inquiry of the person or persons who
<br />manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
<br />belief, true, accurate and complete I am aware that there are significant penalties for submitting false information, including the possibility of fine and
<br />designed I
<br />belief,
<br />n
<br />manage
<br />y under
<br />a the d Pan
<br />en assure that of law
<br />Ira ' 'Uall,,,
<br />. . s
<br />[n,,a aj system, eT e e
<br />u
<br />y T
<br />I ue. accurate
<br />t� and
<br />to true,
<br />- f , ' , I
<br />imprisonment. in addition I certify that the provisions of the permit, including the development and implementation of a Storm Water Po'lution Prevention
<br />Plan and a Monitoring Program Plan, will be complied with,"
<br />Printed
<br />im
<br />Printed Name,
<br />Signature Date
<br />Title-
<br />
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