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STATEWIDE SANITARY SEWER SYSTEMS GENERAL ORDER 2022-0103-DWQ <br />ATTACHMENT B APPLICATION FOR ENROLLMENT <br />1.Enrollment Status:(Mark only oneitem) <br />New Enrollee <br />New Enrollee with previous regulatory coverage under Order 2006-0003-DWQ <br />(that failed to certify continuation of coverage in CIWQS per Order 2022-XXXX-DWQ) <br />Existing WDID Number:__________________________________________________ <br />2.Applicant Information: <br />Legally Responsible Official Submitting Application <br />FirstandLastName:____________________________________________________ <br />Title:_________________________________________________________________ <br />Phone:_______________________________________________________________ <br />Email:________________________________________________________________ <br />System Owner/Operator Name:______________________________________________ <br />Mailing Address:________________________________________________________ <br />City,State, Zip:_________________________________________________________ <br />County:_______________________________________________________________ <br />Sanitary Sewer System Name:____________________________________________ <br />Regional Water Quality Control Board(s):____________________________________ <br />Signatureand Date:_____________________________________________________ <br />3.Applicant Type (Check one): <br />CityCountyStateFederalSpecial District <br />Government CombinationPrivateOther Non-governmental Entity <br />4.Wastewater Treatment Plant Receiving Sanitary Sewer System Waste: <br />Wastewater Treatment Plant Permittee:________________________________________ <br />WDID No.:______________________________________________________________ <br />ATTACHMENT B APPLICATION FOR ENROLLMENTDecember6,2022 <br />B-1 <br /> <br />