Loading...
HomeMy WebLinkAbout1620 e brundage _envirotech report 6.22.20_45-1260:: tto 00W C A L I F O R N I A .Water Boards rte` -..`g GAVIN NEWSOM f30VERriOR n 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