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Outfall Identifier Code. These cannot be <br />symbols. (Maximum of four characters). <br />Surface Waterbody <br />Name at the <br />Outfall <br />Latitude <br />Longitude <br />Example: 001A <br />Example: Puget <br />Sound <br />47.5289047 <br />-122.3123SS0 <br />If your site discharges to a waterbody that is on the impaired waterbodies list (e.g., 303[d] list) for turbidity, <br />fine sediment, high pH, low dissolved oxygen or phosphorus, Ecology will require additional documentation <br />before issuing permit coverage and these sites will be subject to additional sampling and numeric effluent <br />limits (per Permit Condition S8). Ecology will notify you if any additional sampling requirements apply. <br />Information on impaired waterbodies is available online at: Water Quality Assessment & 303(d)List3 <br />Before signing, please use the following checklist to ensure this form is complete: <br />❑ All spaces on this form have been completed. (Attach additional sheets if necessary) <br />❑ The transfer form has been signed by both the current permittee (see Page 1) and the new permittee <br />(see Section VIII below). <br />❑ The date permit responsibility was transferred is specified. (See Page 1) <br />❑ New Operator/Permittee: Before you submit this form to Ecology, please retain a copy for your records <br />—this will serve as proof of permit coverage until documentation arrives from Ecology. <br />❑ For partial transfers: If the original permittee no longer owns or controls any portions of the site that <br />meet the criteria for termination, the original permittee must submit a Notice of Termination (NOT) to <br />terminate permit coverage. See the CSWGP website for a link to the NOT form: Notice of Termination Form' <br />❑ For sites with contaminated soils/groundwater or a new discharge to an impaired waterbody: Any <br />special provisions to protect water quality put in place at the time of initial coverage have been reviewed and <br />adopted by the new permittee. <br />Administrative Order Docket No. <br />3 http://www.ecy.wa.gov/programs/wq/303d/index.html <br />4 https:Happs.ecology.wa.gov/publications/documents/ecy02087.pdf <br />ECY 020-87a (10/2025) <br />