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Location of Discharge to Receiving Water
<br />Enter the water body name, latitude/longhude• of the point(s) where the site discharges to the receiving water
<br />body. (enter all locations)
<br />Latitude Longitude
<br />Receiving Water Body or Type of Oroundwa!x Discharge
<br />degrees, minutes, seconds
<br />degrees, mWwtes, seconds
<br />Snohomish River
<br />Ar M ,ZZ N
<br />]22° St' It W
<br />N
<br />W
<br />N
<br />W
<br />N
<br />W
<br />_' _ N
<br />W
<br />For assistance with latitude and longitude refer to: httgJ/cfnubl M aov/noderr/atorrnwate0atiorra.c/m
<br />(o, Nww.tovozorre-com) orhttc://www.eva.aov/tri/reoort/sitino tooklndex.htm
<br />vtu. toxormwater routtnon rrevernion rtan iwrrr
<br />Hasa SW PPP been developed that includes a narrative and drawings? []Yes ® No
<br />N NO, the SWPPP MWj be completed prior to start of construction.
<br />) XI. Certification of New Permittee )
<br />"I certify under penalty of law that this document and all attachments were prepared under my direction or
<br />supervision in accordance with a system designed to assure that qualified personnel properly gather and
<br />evaluate the information submitted. Based on my inquiry of the person or persons who manage the system or
<br />those directly responsible for gathering the information, the information submitted is. to the best of my
<br />knowledge and belief, true, accurate, and complete. I 'im aware that there are significant penalties for
<br />submitting false information, including the possibility of fine and imprisonment for knowing violations."
<br />Operator's Printed Name _ Title
<br />Operators Signature Date
<br />Please sign and return this document to the following address:
<br />If you have any questions, please call:
<br />Washington Department of Ecology
<br />Water Quality Program
<br />Construction Stormwater Unit
<br />P. O. Box 47696
<br />Olympia, WA 98504-7696
<br />0 360-407-7451 Charles Gilman for city of Seattle or counties: Kitsap, Pierce, Thurston
<br />0 360-407-7229 Tammie McClure for counties: King, Island, San Juan
<br />0 360-407-6437 Linda Matlock for counties: Whatcom, Skagit, Snohomish, Ferry, Stevens, Pend Oreille,
<br />Lincoln, Spokane, Grant, Adams, Whitman, Franklin, Walla Walla, Columbia, Garfield, Asotin
<br />0 360-407-6858 Joyce Smith for counties: Okanogan, Chelan, Douglas, Kittitas, Yakima, Benton,
<br />Klickitat, Skamania, Clark, Cowlitz, Wahkiakum, Lewis, Pacific, Grays Harbor, Mason, Jefferson,
<br />Clailam
<br />The Department of Ecology is an equal opportunity agency and does not discriminate on the basis of race, creed, color, disability, age,
<br />religion, national origin, sex, marital status, disabled veteran's status, Vietnam Era veferan's status, or sexual drientarbn.
<br />ECY 020-87a (Rev 12/05)
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