Page 108 - _ 180314 Special Yucaipa GSA Packet

2012 Certified Nationwide Permit Notification Form
TO COMPLY WITH THE TERMS OF
GENERAL WATER QUALITY CERTIFICATION OF 2012 NATIONWIDE PERMITS
ORDER NUMBER SB12002GN
A SIGNED NOTIFICATION MUST BE RECEIVED BY THE STATE WATER BOARD AND THE
APPROPRIATE REGIONAL WATER BOARD NO LESS THAN 45 DAYS BEFORE ANY PROJECT
ACTIVITY

This application is for coverage under Order No. SB12002GN for Nationwide Permit:
Mark only one item
Scientific Measurement Devices NWP 5 ☐
Survey Activities NWP 6 ☐

Temporary Recreational Structures NWP 11 ☐
Utility Line Activities NWP 12 ☐

Response Operations for Oil and Hazardous NWP 20 ☐
Substances
Removal of Vessels NWP 22 ☐
Modification of Existing Marinas NWP 28 ☐

Completed Enforcement Actions NWP 32 ☐
Boat Ramps NWP 36 ☐

Important Note: The applicant listed shall be the party responsible for compliance with the Clean Water Act, California Water
Code, applicable Water Quality Control Plan, and 401 Certification Conditions and is typically the property/facility owner. The
authorized agent is the individual or team that is authorized by the applicant to provide information to the Regional Water
Board on behalf of the applicant (responsible party).

(a) Applicant Identification
Name and Title of Applicant

Applicant Mailing Address

City County State Zip

Email FAX Phone (office)

Phone (cell)

FEE CHECK: Attach fee check here, payable to State Water Resources Control Board.

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Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 104 of 226