This application package constitutes a Report of Waste Discharge (ROWD) pursuant to California Water Code Section 13260. Section 13260 states that persons discharging or proposing to discharge waste that could affect the quality of the waters of the State, other than into a community sewer system, shall file a ROWD containing information which may be required by the appropriate Regional Water Quality Control Board (RWQCB).
This package is to be used to start the application process for all waste discharge requirements (WDRs) and National Pollutant Discharge Elimination System (NPDES) permits* issued by a RWQCB except:
This application package contains:
Instructions are provided to assist you with completion of the application. If you are unable to find the answers to your questions or need assistance with the completion of the application package, please contact your RWQCB representative. The RWQCBs strongly recommend that you make initial telephone or personal contact with RWQCB regulatory staff to discuss a proposed new discharge before submitting your application. The RWQCB representative will be able to answer procedural and annual fee related questions that you may have. (See map and telephone numbers inside of application cover.)
All dischargers regulated under WDRs and NPDES permits must pay an annual fee, except dairies, which pay a filing fee only. The RWQCB will notify you of your annual fee based on an evaluation of your proposed discharge. Please do NOT submit a check for your first annual fee or filing fee until requested to do so by a RWQCB representative. Dischargers applying for reissuance (renewal) of an existing NPDES permit or update of an existing WDR will be billed through the annual fee billing system and are therefore requested NOT to submit a check with their application. Checks should be made payable to the State Water Resources Control Board.
A RWQCB representative will notify you within 30 days of receipt of the application form and any supplemental documents whether your application is complete. If your application is incomplete, the RWQCB representative will send you a detailed list of discharge specific information necessary to complete the application process. The completion date of your application is normally the date when all required information, including the correct fee, is received by the RWQCB.
*NPDES PERMITS: If you are applying for a permit to discharge to surface water, you will need an NPDES permit which is issued under both State and Federal law and may be required to complete one or more of the following Federal NPDES permit application forms: Short Form A, Standard Form A, Forms 1, 2B, 2C, 2D, 2E, and 2F. These forms may be obtained at a RWQCB office or can be ordered from the National Center for Environmental Publications and Information at (513) 891-6561
Water Boards
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.
You must provide the factual information listed below for ALL owners, operators, and locations and, where appropriate, for ALL general partners and lease holders.
Owner Type: Check the appropriate owner type. The legal owner will be named in the WDRs/NPDES permit.
Address where annual fee invoices should be sent, person to contact, and phone number. If identical to B. above, enter 'same as owner'.
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Mark the appropriate box to describe whether the waste will be discharged to: Land or Surface Water.
Check the appropriate box(es) which best describe the activities at your facility.
Hazardous Waste: If you check the Hazardous Waste box, STOP and contact a representative of the RWQCB for further instructions.
Landfills: A separate form, APPLICATION FOR SOLID WASTE FACILITY PERMIT/WASTE DISCHARGE REQUIREMENTS, California Integrated Waste Management Board Form E-1-77, may be required. Contact a RWQCB representative to help determine the appropriate form for your discharge.
NEW DISCHARGE OR FACILITY: A discharge or facility that is proposed but does not now exist, or that does not yet have WDRs or an NPDES permit.
CHANGE IN DESIGN OR OPERATION: A material change in design or operation from existing discharge requirements. Final determination of whether the reported change is material will be made by the RWQCB.
CHANGE IN QUANTITY/TYPE OF DISCHARGE: A material change in characteristics of the waste from existing discharge requirements. Final determination of whether the reported change would have a significant effect will be made by the RWQCB.
CHANGE IN OWNERSHIP/ OPERATOR: Change of legal owner of the facility. Complete Parts I, III, and IV only and contact the RWQCB to determine if additional information is required.
REISSUANCE: WDRs must be updated periodically to reflect changing technology standards and conditions. A new application is required to reissue an NPDES permit which has expired.
OTHER: If there is a reason other than the ones listed, please describe the reason on the space provided. (If more space is needed, attach a separate sheet.)
It should be emphasized that communication with the appropriate RWQCB staff is vital before starting the CEQA documentation and is recommended before completing this application. There are Basin Plan issues which may complicate the CEQA effort, and RWQCB staff may be able to help in providing the needed information to complete the CEQA documentation.
Name the Lead Agency responsible for completion of CEQA requirements for the project, i.e., completion and certification of CEQA documentation.
Check YES or NO. Has a public agency determined that the proposed project is exempt from CEQA? If the answer is YES, state the basis for the exemption and the name of the agency supplying the exemption on the space provided. (Remember that, if extra space is needed, use an extra sheet of paper, but be sure to indicate the attached sheet under Section VII. Other.)
Check YES or NO. Has the 'Notice of Determination' been filed under CEQA? If YES, give the date the notice was filed and enclose a copy of the Notice of Determination and the Initial Study, Environmental Impact Report, or Negative Declaration. If NO, check the box of the expected type of CEQA document for this project, and include the expected date of completion using the timelines given under CEQA. The date of completion should be taken as the date that the Notice of Determination will be submitted. (If not known, write 'Unknown')
To be approved, your application MUST include a COMPLETE characterization of the discharge. If the characterization is found to be incomplete, RWQCB staff will contact you and request that additional specific information be submitted.
This application MUST be accompanied by a site map. A USGS 7.5' Quadrangle map or a street map, if more appropriate, is sufficient for most applications.
If any of the answers on your application form need further explanation, attach a separate sheet. Please list any attachments with the titles and dates on the space provided.
Certification by the owner of the facility or the operator of the facility, if the operator is different from the owner, is required. The appropriate person must sign the application form.
Acceptable signatures are:
In most cases, a request to supply additional discharge specific information will be sent to you by a representative of the RWQCB. If the RWQCB determines that additional discharge specific information is not needed to process your application, you will be so notified.
Name
Address
City/County/State/Zip Code
Contact Person
Telephone Number
Name
Address
City/State/Zip Code
Contact Person
Telephone Number
Federal Tax ID
Owner Type ( Mark one ):
Individual
Corporation
Governmental Agency
Partnership
Other:
Name
Address
City/State/Zip Code
Contact Person
Telephone Number
Operator Type ( Mark one ):
Individual
Corporation
Governmental Agency
Partnership
Other:
Name
Address
City/State/Zip Code
Contact Person
Telephone Number
Owner Type ( Mark one ):
Individual
Corporation
Governmental Agency
Partnership
Other:
Address
City/State/Zip Code
Contact Person
Telephone Number
Address
City/State/Zip Code
Contact Person
Telephone Number
Check Type of Discharge(s) Described in this Application:
Waste Discharge to Land
Waste Discharge to Surface Water
Check all that apply:
Animal or Aquacultural Wastewater
Land Treatment Unit
Animal Waste Solids
Landfill ( see instructions )
Biosolids/Residual
Mining
Cooling Water
Storm Water
Domestic/ Municipal Wastewater Treatment and Disposal
Surface Impoundment
Dredge Material Disposal
Waste Pile
Hazardous Waste ( see instructions )
Wastewater Reclamation
Industrial Process Wastewater
Other, please describe
Describe the physical location of the facility:
Facility:
Discharge Point:
Facility:
Discharge Point:
Facility:
Discharge Point:
Check all that apply:
New Discharge or Facility
Change in Design or Operation
Change in Quantity/Type of Discharge
Changes in Ownership/Operator (see instructions)
Waste Discharge Requirements Update or NPDES Permit Reissuance
Other:
Name of Lead Agency
Has a public agency determined that the proposed project is exempt from CEQA?
Yes
No
If yes, state the basis for the exemption and the name of the agency supplying the exemption on the line below:
Has a 'Notice of Determination' been filed under CEQA?
Yes
No
If Yes, enclose a copy of the CEQA document, Environmental Impact Report (EIR), or Negative Declaration. If No, identify the expected type of CEQA document and expected date of completion.
Expected CEQA Documents:
EIR
Negative Declaration
Expected CEQA Completion Date:
Please provide a COMPLETE characterization of your discharge. A complete characterization includes, but is not limited to, design and actual flows, a list of constituents and the discharge concentration of each constituent, a list of other appropriate waste discharge characteristics, a description and schematic drawing of all treatment processes, a description of any Best Management Practices (BMPs) used, and a description of disposal methods.
Also include a site map showing the location of the facility and, if you are submitting this application for an NPDES permit, identify the surface water to which you propose to discharge. Please try to limit your maps to a scale of 1:24,000 (7.5' USGS Quadrangle) or a street map, if more appropriate.
Attach additional sheets to explain any responses which need clarification. List attachments with titles and dates below:
You will be notified by a representative of the RWQCB within 30 days of receipt of your application. The notice will state if your application is complete or if there is additional information you must submit to complete your Application/Report of Waste Discharge, pursuant to Division 7, Section 13260 of the California Water Code.
"I certify under penalty of law that this document, including all attachments and supplemental information, were prepared under my direction and supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment."
Print Name
Title
Signature
Date
Date Form 200 Received:
Letter to Discharger:
Fee Amount Received:
Check #:
California Environmental Protection Agency (Cal/EPA) recognizes that many complex issues must be addressed when pursuing reforms of environmental permits and that significant challenges remain. We have initiated reforms and intend to continue the effort to make environmental permitting more efficient, less costly, and to ensure that those seeking permits receive timely responses from the boards and departments of the Cal/EPA. To further this goal, Cal/EPA endorses the following precepts that form the basis of a permit applicant's "Bill of Rights."