PERMIT FOR INDUSTRIAL WASTEWATER DISCHARGE COUNTY SANITATION DISTRICTS OF LOS ANGELES COUNTY 1955 Workman Mill Road / Whittier, CA Mailing Address: P.O. Box 4998 / Whittier, California 90607-4998 Grace Robinson Hyde, Chief Engineer and General Manager (562) 699-7411 01 02 PERMIT NO: CHECK ONE: Applicant New Sewer Connection Existing Sewer Connection (Legal Company Name) 03 Check one and fill in appropriate information Corporation Name Year Incorporated Partnership Name Sole Proprietor Name 04 State of Incorporation Partners Business Names (City) (City) (State) (State) ID# Situs Address (Street) (Zip) (Zip) 05 Mailing Address (Street) 06 07 Point of Discharge Number of years applicant has been in business at present location (yrs) (months) 08 Name of Property Owner Address of Property Owner (Street) (City) (Zip) (Telephone Number) 09 10 Assessors Map Book No. Type of Industry (General Description) Page No. Parcel No. , (Federal SIC No.) 11 12 Number of Employees (Full Time) Raw Materials Used (Part Time) (General Description ­ Add Additional Sheets as Needed) (Daily Amount Used) 13 Products Produced (General Description ­ Add Additional Sheets as Needed) (Daily Amount Produced) 14 Wastewater Producing Operations (Full Description ­ Add Additional Sheets as Needed) 15 16 Time of Discharge Wastewater Flow Rate AM PM (Average) AM PM , Shifts per day Gallons per Day M T W Th Days per Week F Sa Su Gallons per Minute (Peak) 17 Constituents of Wastewater Discharge (General Description ­ Attach Chemical Analysis Results to the Application) 18 Person in company responsible for industrial wastewater discharge (Name) (Position) (Telephone Number) I affirm that all information furnished is true and correct and that the applicant will comply with the conditions stated on the back of this permit form. Date ,20 19 Signature for Applicant (Company Administrative Official) 20 (Name) (Position) Approved/Reviewed by City or County Official Date L.A. County Department of Public Works City of Name Position Approved by Sanitation Districts of Los Angeles County Date Expiration Date Grace Robinson Hyde, Chief Engineer and General Manager By Position Note: Please submit application first to the applicable City or County agency in which the point of discharge is located. Please contact the local agency for the required permit-processing fee. Submit the original application (Do not send copies). CONTINUED ON NEXT PAGE American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT FOR PERMIT MUST READ THIS MATERIAL IN CONSIDERATION OF THE GRANTING OF THIS PERMIT, the applicant agrees: 1. To furnish any additional information on industrial wastewater discharges as required by the Districts, 2. To accept and abide by all provisions of ordinances, policies and guidelines of the Districts, 3. To operate and maintain any required industrial wastewater treatment devices in a satisfactory approved manner, 4. To cooperate at all times with Districts' personnel, or their representatives, in the inspection, sampling and study of industrial wastewater facilities and discharges, 5. To immediately notify the Districts at (562) 699-7411 during normal working hours or (562) 437-6520 or 437-1881 after 4:00 P.M. or on weekends in the event of any accident, negligence or other occurrence that causes the discharge to the sewer of any material whose nature and quantity might be reasonably judged to constitute a hazard to the public health, environment, Districts' personnel or wastewater treatment facilities, 6. To pay to the Districts annually the required surcharge or user charge fee for industrial wastewater treatment, 7. To submit, as required by the Districts, accurate data on industrial wastewater discharge flows and wastewater constituents, 8. To operate only one industrial wastewater discharge point to the sewerage system under the authority granted by this permit, 9. To submit additional pages as required for furnish the necessary information if there is inadequate room on the reverse side of this permit form to complete submittal of requested data, 10. To apply for a revised Districts' Industrial Wastewater Discharge Permit if any change in industrial processes, production, method of wastewater treatment or operations creates a significant change in industrial wastewater quality, or if the quantity of wastewater discharged changes by more than 25% or other threshold level as specified in industrial waste permit requirements, 11. To provide immediate access to authorized personnel of the Districts to any facility directly or indirectly connected to the Districts' sewerage system under emergency conditions and at all other reasonable times. American LegalNet, Inc. www.FormsWorkFlow.com