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J,AREO BLUMENFELD
SECRETARY FOR
ENVIRONMENTAL PROTECTION
State of California
Regional Water Quality Control Board
APPLICATIONIREPORT OF WASTE DISCHARGE
GENERAL INFORMATION FORM FOR
WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT
INSTRUCTIONS
Instructions for completing the application /report of waste discharge general information
form for: waste discharge requirements/ NPDES permit.
If you have any questions on the completion of any part of the application, please
contact your RWQCB representative. A map of RWQCB locations, addresses, and
telephone numbers is located on the reverse side of the application cover.
I. FACILITY INFORMATION
You must provide the factual information listed below for ALL owners, operators,
and locations and, where appropriate, for ALL general partners and lease holders.
A. FACILITY: Legal name, physical address including the county, person to
contact, phone number, and email at the facility. (NO P.O. Box numbers. If no
address exists, use street and nearest cross street).
B. FACILITY OWNER: Legal owner, address, person to contact, phone number,
and email. Also include the owner's Federal Tax Identification Number.
Owner Type: Check the appropriate owner type. The legal owner will be
named in the WDRs /NPDES permit.
C. FACILITY OPERATOR (The agency or business, not the person): If
applicable, the name, address, person to contact, telephone number, and email
for the facility operator. Check the appropriate Operator Type. If identical to B.
above, enter "same as owner ".
D. OWNER OF THE LAND: Legal owner of the land(s) where the facility is
located, address, person to contact, and phone number. Check the appropriate
Owner Type. If identical to B. above, enter "same as owner ".
E. ADDRESS WHERE LEGAL NOTICE MAYBE SERVED: Address where legal
notice may be served, person to contact, and phone number. If identical to B.
above, enter "same as owner ".
Address where annual fee invoices should be sent, person to contact, and
phone number. If identical to B. above, enter "same as owner ".
Form 200 (10/97) 3