Fillable City of San Dimas SB 205 Stormwater Discharge (City of San Dimas)

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City of San Dimas SB 205 Stormwater Discharge (City of San Dimas)

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City of San Dimas
SB 205 Stormwater Discharge Compliance Form
<2
nd
Page on Back>
Business License #_____________
Completion of this form is required with your business license application/renewal.
Business license certificates will not be sent until we receive this form completed.
Senate Bill (SB) 205, signed by Gov. Newsom in 2019, requires a person or entity who conducts a
business operation that is a “regulated industry” to demonstrate enrollment with the National
Pollutant Discharge Elimination System (NPDES) permit program. By providing specified
information on an initial or renewal City business license application, enrollment in the NPDES
permit can be confirmed. The goal of the program is to address the health and safety of drinking
water sources statewide.
Business Name:________________________________________________________________
Location/Address:______________________________________________________________
Phone #:___________________________ Email:_____________________________________
Brief Business Description: ___________________________________________________________
_____________________________________________________________________________________
1
What is/are the primary Standard Industrial Classification
(SIC) codes for this business location?
SIC Codes can be found here:
https://www.osha.gov/pls/imis/sicsearch.html
Search by keyword(s) (for example: metal recycling)
__________
__________
2
Are any of the SIC codes from question #1 listed on the Water
Board website as one of the regulated SIC codes?
www.waterboards.ca.gov/water_issues/programs/stormwater/sic.shtml
Check One
Yes
No
3
If you circled NO to Question #2, sign the back of the form and
submit with your application or renewal. Nothing more for
SB205 is required of the business at this time.
Continue to Back
4
If you circled YES in Question #2, has the business already obtained
an Industrial NPDES Permit?
Check One
Yes
No
5
If you circled YES in Question #4, provide the requested information
regarding the existing Industrial NPDES Permit. Sign the back of the
page and submit with your application or renewal. You are in
compliance with SB205.
WDID# _______________________
WDID Application #_____________
NONA ID# ____________________
NEC ID# ______________________
City of San Dimas
SB 205 Stormwater Discharge Compliance Form
6
If you circled NO in Question #4, you need to enroll under the
Stormwater Industrial General Permit (IGP) and provide the City
with your permit numbers as described in Question #5 above.
Sign and return this SB205 Compliance Form with your business
application/renewal now. Start the process of obtaining the Industrial
General Permit by contacting the State or Regional Water Board at the
information listed below. The City will issue you a 3-month provisional
business license while you obtain the IGP and report the permit numbers
to the City.
Declaration
I declare under penalty of perjury under the laws of California that the above information is true
and correct to the best of my knowledge.
Print Name: ________________________ Signature: ___________________________
Title: ______________________________ Date: _______________________________
For guidance on how to apply for coverage under the Stormwater Industrial General Permit,
contact the State Water Board or local Regional Board.
State Water Board Contact:
Website: www.waterboards.ca.gov/waterboards_map.html
Email: stormwater@waterboards.ca.gov
Phone: 1-866-563-3107
Region 4 Los Angeles Regional Water Board – Los Angeles Office Contact:
Website: https://www.waterboards.ca.gov/losangeles/
Phone: 1-213-576-6600
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City of San Dimas SB 205 Stormwater Discharge (City of San Dimas)

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Completed 16 July 2020

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