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M <br /> 5. Location of facility <br /> Longitude Latitude <br /> Legal description(Township, Range, 1/4 Section) <br /> Street County <br /> City State Zip Code <br /> Local Contact(familiar with facility) <br /> Telephone Number 1 1 Title <br /> Please provide directions to the operation from a nearby town or landmark. <br /> 6. Type of activity: e.g.,building construction, general construction,highway bridge and tunnel construction,etc. and a description of <br /> activities being performed, including construction schedule and months of operation. Specify source(s)of wastewater to be discharged(i.e. <br /> groundwater,stormwater runoff). <br /> 7. Do you anticipate the need for changing or adding the discharge point(s)as construction progresses? If sa,briefly explain. <br /> 8. A location map designating the facility property and discharge points shall be submitted. The map shall be from a 7 'h or 15 minute USGS <br /> quad sheet or a map of comparable scale. A north arrow shall be shown. Any public water supply intakes within a 5 mile radius of the <br /> facility shall also be identified, if known(see item 20). This map must be on paper 8 1A x 11 inches. <br /> 9. A legible sketch of the site shall be submitted and include appurtenant facilities (buildings,ponds, diversion ditches, etc.),stream location, <br /> numbered discharge points, sampling and flow monitoring points. Sketch shall be on paper 8 1/2 x 11 inches. Label the outfalls on the <br /> sketch to correspond with the numbers listed in 10. <br /> 10. Will the discharge go to a ditch, storm sewer, or any other type of conveyance? ❑ YES ❑ NO <br /> If YES,submit documentation that the owner of the ditch, storm sewer,or any other type of conveyance,allows this discharge. No <br /> certification will be processed unless documentation of approval is received. <br /> 11. Method of flow measurement for each discharge(i.e. 90'v-notch weir, pump capacity,parshall flume, etc.). Designate whether currently <br /> installed or proposed. <br /> 12. Do you have bulk storage of diesel fuel,.gasoline,solvents or other hazardous materials on site? ❑ YES, ❑ NO <br /> DEWA EMG-"3 ��� <br />