DISCHARGE LOCATION INFORMATION Discharge path to Receiving Water - describe the complete path of the discharge from the exit point of the treatment system to the outfall in the receiving water – list streets, land features, and distances as necessary. Discharge Points Latitude1 Longitude1 Receiving Name Effluent Monitoring (EFF-001 through EFF-n) Not Applicable Drain (if applicable) Not Applicable Receiving Water (directly of via storm drain system) Upstream Receiving Water Monitoring Location (RSW-001U through RSW-nU) At a 50 feet upstream from the point of discharge into the receiving water, or if access is limited, at the first point upstream which is accessible. Is access unrestricted? ☐ Yes ☐ No If No, provide details: Downstream Receiving Water Monitoring Location (RSW-001D through RSW-nD) At a point 50 feet downstream from the point of discharge into the receiving water, or if access is limited, at the first point downstream which is accessible. Is access unrestricted? ☐ Yes ☐ No If No, provide details: Submit latitude and longitude coordinates in decimal degrees with 5 significant figures to the right of the decimal point. □ Check here if information for additional outfalls is attached to this form. TREATMENT SYSTEM INFORMATION A. General Information Groundwater Treatment Design Capacity (gpm) as certified by a Professional Engineer licensed to practice in California. Discharge description (describe discharge and potential pollutants of concern. Attach additional sheets if needed: Discharge Frequency: ☐ Continuous ☐Daily ☐ Intermittent ☐Emergency (explain): Estimated Total Water Reclaimed (%): Provide reasons if reclamation is not technically and economically feasible: Type of Reclamation (e.g., dust control):
CTR No. Parameter Units Average Monthly Effluent Limitation Maximum Daily Effluent Limitation Maximum Concentration Range Method Detection Limit Test Method Number of Samples 99 Phenanthrene µg/L 100 Pyrene µg/L 101 1,2,4-Trichlorobenzene µg/L 102 Aldrin µg/L 103 µg/L 104 beta-BHC µg/L 105 gamma-BHC µg/L 106 delta-BHC µg/L 107 Chlordane (303d listed) µg/L 108 4,4'-DDT (303d listed) µg/L 109 4,4'-DDE µg/L 110 4,4'-DDD µg/L 111 Dieldrin (303d listed) µg/L 112 µg/L 113 beta-Endolsulfan µg/L 114 Endosulfan Sulfate µg/L 115 Endrin µg/L 116 Endrin Aldehyde µg/L 117 Heptachlor µg/L 118 Heptachlor Epoxide µg/L 119- 125 PCBs sum (303d listed) µg/L 126 Toxaphene µg/L Discharge Point No. – Other Pollutants Parameter Average Monthly Effluent Limitation Maximum Daily Effluent Limitation Maximum Concentration Range Method Detection Limit Test Method Number of Samples TPH as gasoline µg/L TPH as diesel µg/L TPHs (other than gasoline and diesel) µg/L Sulfate mg/L Foaming Agents µg/L Electric conductivity mmhos/cm Manganese µg/L ENGINEERING CERTIFICATION REPORT Attach the engineering certification report signed and stamped by the Design Professional Engineer licensed to practice in California and as identified in section VI.D. The Engineering Certification Report shall include a location map, discharge flow path map, process flow diagram, unit spec sheets, and a description of operation and maintenance procedures. Please see the next section for further details of the documents required as part of the Engineering Certification Report and NOI application package.