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CITY <br /> EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 <br /> 110016662011 WA0024490 City of Everett WPCF OMB No.2040-0004 <br /> 5.7 Provide the information in the table below for each of your CSO outfalls. <br /> CSO Outfall Number CSO Outfall Number CSO Outfall Number <br /> Receiving water name <br /> Name of watershed/ <br /> stream system <br /> U.S.Soil Conservation 0 Unknown 0 Unknown 0 Unknown <br /> Service 14-digit <br /> c watershed code <br /> > (if known) <br /> Name of state <br /> cc management/river basin <br /> 0 U.S.Geological Survey ❑Unknown 0 Unknown 0 Unknown <br /> 8-Digit Hydrologic Unit <br /> Code(if known) <br /> Description of known <br /> water quality impacts on <br /> receiving stream by CSO <br /> (see instructions for <br /> examsles <br /> SECTION 6.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d)) <br /> 6.1 In Column 1 below,mark the sections of Form 2A that you have completed and are submitting with your application.For <br /> each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority.Note that not <br /> all applicants are required to provide attachments. <br /> Column 1 Column 2 <br /> • Section 1: Basic Application <br /> Information for All Applicants ❑ w/variance request(s) ❑ w/additional attachments <br /> ❑ Section 2:Additional ✓❑ w/topographic map ✓❑ w/process flow diagram <br /> Information ✓❑ w/additional attachments <br /> ✓❑ w/Table A ✓❑ w/Table D <br /> ❑✓ Section 3: Information on ✓❑ w/Table B ❑ w/Table E <br /> Effluent Discharges <br /> ✓❑ w/Table C ✓❑ w/additional attachments <br /> Section 4: Industrial ❑ w/SIU and NSCIU attachments ❑✓ w/Table F <br /> (7) ❑✓ Discharges and Hazardous <br /> c Wastes ❑ w/additional attachments <br /> ❑ Section 5:Combined Sewer ✓❑ w/CSO map ❑✓ w/additional attachments <br /> U Overflows ✓❑ wl CSO system diagram <br /> Section 6:Checklist and <br /> R ❑ Certification Statement ❑ w/attachments <br /> :�e 6.2 Certification Statement <br /> I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in <br /> accordance with a system designed to assure that qualified personnel properly gather and evaluate the information <br /> submitted.Based on my inquiry of the person or persons who manage the system,or those persons directly responsible <br /> for gathering the information,the information submitted is,to the best of my knowledge and belief,true,accurate, and <br /> complete. I am aware that there are significant penalties for submitting false information,including the possibility of fine <br /> and imprisonment for knowing violations. <br /> Name(print or type first and last name) Official title <br /> Cassie Franklin Mayor <br /> Signature Date signed <br /> EPA Form 3510-2A(Revised 3-19) AT S T. Page 12 <br /> City Clerk <br />