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STATEWIDE SANITARY SEWER SYSTEMS GENERAL ORDER 2022-0103-DWQ <br />5. Billing Information <br />Billing Address: <br />City, State, Zip: <br />Billing Contact Person and Title: <br />Phone and Email Address: <br />6. Application Fee: <br />The application fee, as required by Water Code section 13260, is based on the daily <br />population served by the sanitary sewer system. See updated Fee Schedule. <br />(https://www.waterboards.ca.gov/resources/fees/water_quality/) <br />Check one of the following and enter fee amount: <br />❑ Population Served < 50,000 — Total Fee submitted: $ <br />❑ Population Served > 50,000 — Total Fee submitted: $ <br />Make the fee payment payable to the State Water Resources Control Board and mail the <br />complete application package to: <br />State Water Resources Control Board, Accounting Office <br />P. O. Box 1888 <br />Sacramento, CA 95812-1888 <br />Attention: Statewide Sanitary Sewer System Program <br />7. Application Submittal Certification <br />1 certify under penalty of perjury under the laws of the State of California that to the best of <br />my knowledge and belief, the information in the submitted application package is true, <br />accurate and complete. 1 am aware that there are significant penalties for submitting false <br />information, including the possibility of fines and imprisonment. <br />rdIs,a►FTiL- <br />Title: <br />Signature: <br />Date: <br />ATTACHMENT B — APPLICATION FOR ENROLLMENT December 6, 2022 <br />B - 2 <br />