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Attachment A A-3 <br /> Reissued Waste Discharge Requirements General Order No. R5-2013-0122 <br /> Existing Milk Cow Dairies <br /> G. CHEMICAL USE: <br /> INDICATE ALL CHEMICALS USED AT THE FACILITY THAT ARE STORED IN THE WASTE STORAGE SYSTEM OR THAT <br /> COULD BE DISCHARGED TO SURFACE WATER OR GROUNDWATER AND THE APPROXIMATE AMOUNTS USED <br /> ANNUALLY(ATTACH ADDITIONAL SHEETS AS NECESSARY): <br /> TYPE APPROXIMATE ANNUAL AMOUNT USED <br /> SOAPS <br /> DISINFECTANTS <br /> PESTICIDES <br /> FOOTBATHS <br /> OTHER <br /> H. SITE MAP: <br /> PROVIDE A SITE MAP(AERIAL OR TOPOGRAPHIC)OF YOUR DAIRY WHICH SHOWS THE FOLLOWING IN SUFFICIENT <br /> DETAIL: DAIRY FACILITY PROPERTY BOUNDARIES; LOCATIONS OF ALL MONITORING, DOMESTIC,AND IRRIGATION <br /> WELLS; PROCESS WASTEWATER RETENTION PONDS;MILKING PARLOR;ANIMAL HOUSING;CORRALS;AND ALL <br /> LAND APPLICATION AREAS WITH IDENTIFICATION OF LAND USED FOR APPLICATION OF MANURE AND/OR <br /> PROCESS WASTEWATER. <br /> CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) COMPLIANCE <br /> A. WAS YOUR DAIRY OPERATING AT ITS CURRENT LOCATION AS OF 17 OCTOBER 2005? YES NO <br /> IF YES, HAS YOUR DAIRY EXPANDED BY MORE THAN 15%SINCE 17 OCTOBER 2005? YES NO <br /> IF YES(I.E.,YOUR DAIRY DID EXPAND BY MORE THAN 15%), DID YOU SUBMIT A REPORT OF WASTE DISCHARGE <br /> (ROWD)TO THE CENTRAL VALLEY WATER BOARD FOR THE EXPANSION? YES NO <br /> CERTIFICATION <br /> "I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND AM FAMILIAR WITH THE INFORMATION <br /> SUBMITTED IN THIS DOCUMENT AND ALL ATTACHMENTS AND THAT,BASED ON MY INQUIRY OF THOSE INDIVIDUALS <br /> IMMEDIATELY RESPONSIBLE FOR OBTAINING THE INFORMATION, I BELIEVE THAT THE INFORMATION IS TRUE, <br /> ACCURATE,AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE <br /> INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT. IN ADDITION, I CERTIFY THAT THE <br /> PROVISIONS OF WASTE DISCHARGE REQUIREMENTS GENERAL ORDER NO.R5-2013-0122, INCLUDING THE <br /> DEVELOPMENT AND IMPLEMENTATION OF A NUTRIENT MANAGEMENT PLAN AND WASTE MANAGEMENT PLAN,WILL BE <br /> COMPLIED WITH." <br /> SIGNATURE OF OWNER OF FACILITY SIGNATURE OF OPERATOR OF FACILITY <br /> PRINT OR TYPE NAME PRINT OR TYPE NAME <br /> TITLE AND DATE TITLE AND DATE <br />