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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 one item) <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 />First and Last Name: <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 />Signature and Date: <br />3. Applicant Type (Check one): <br />❑ City ❑ County ❑ State ❑ Federal ❑ Special District <br />❑ Government Combination ❑ Private ❑ Other 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 ENROLLMENT December 6, 2022 <br />B - 1 <br />