Page 173 - California Stormwater Workshop Handouts

ATTACHMENT D

PERMIT REGISTRATION DOCUMENTS (PRDS)

Street Address
Address Line 2
City/State/Zip
Phone Ex (999-999-9999)
E-mail ([email protected])
Federal Tax ID

b. Facility Information

Facility Name
Contact First Name
Contact Last Name
Title
Street Address
Address Line 2
City
County
Phone Ex (999-999-9999)
Emergency Phone Ex (999-999-9999)
E-mail ([email protected])
State/Zip CA
Total Site Size (Acres)
Latitude (Decimal degrees only, minimum 5 significant digits, Ex 99.99999)
Longitude (Decimal degrees only, minimum 5 significant digits, Ex 99.99999)
Percent of Site Imperviousness (%)
Primary SIC Code
Secondary SIC Code
Tertiary SIC Code
Regional Water Board

c. Billing Information

Billing Name (if different than Operator/Owner)
Contact First Name
Contact Last Name
Title
Street Address
Address Line 2
City/State/Zip
Phone E.g. (999-999-9999)
E-mail (e.g. [email protected])

d. SMARTS Electronic Authorization Form - Signed by any user authorized to
certify and submit data electronically.

Order 2014-0057-DWQ 6