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i <br /> Instructions for completing Trucked Non-Hazardous Waste Disposal Permit <br /> (Pages 1 and 2) <br /> Please Type or Print the Requested Information <br /> Permit Application Business Name—Enter the name of the business that has legal responsibility for wastewater <br /> discharge,including responsibility for any enforcement actions or penalties imposed by the District.Upon approval of <br /> the permit,this will be the permitted party. This party,or permit holder,will also provide both Addendum A(Waste <br /> Acceptance Agreement)and Addendum B(Certification of Liability). <br /> EBMUD Permit Number and Expiration Date-will be completed by EBMUD. <br /> Permit Holder Applicant Contact Information—Enter the applicant's business contact information. <br /> Permit Holder Billing Contact Information—Enter the billing contact information. <br /> Under Sections:"Enforcement and Penalty"and"Certification"reference is made to Ordinance 311A-03. This <br /> document may be obtained from our website: <br /> http://www.ebmud.com/water &_environment/wastewater/industrial_&_commercial_permits—&_fees/wastewater control <br /> ordinance/default.htm — <br /> Permit Applicant Signature—Enter the name and title of the person signing the application. The person signing the <br /> application must meet the signatory criteria of 40.CFR 403.12(l). Persons meeting these criteria include: <br /> 1) A responsible corporate officer,such as: <br /> a. a president,vice-president,secretary,treasurer,or other person performing similar policy or decision <br /> making functions or; <br /> b. a manager of one or more manufacturing,production,or operating facilities. The facility must employ <br /> more than 250 persons or have gross annual sales or expenditures exceeding$25 million(in second-quarter <br /> 1980 dollars). The person must have authority to sign documents. <br /> 2) A general partner or sole proprietor. <br /> 3) A duly authorized representative. The duly authorized representative must be: <br /> a, an individual having responsibility for the overall operation of the facility from which the wastewater <br /> discharge originates. Examples include plant manager,field superintendent,or environmental manager; <br /> b. authorized in writing by a person described in paragraph 1)or 2). The written authorization must be <br /> submitted to the District. <br /> Return the Signed Original Application to: <br /> East Bay Municipal Utility District <br /> Resource Recovery Program,MS 702 <br /> P.O.Box 24055 <br /> Oakland,CA 94623-1055 <br />