Appendix A. Notice of Appeal

(If this form does not give you adequate space, attach additional sheets of paper.) BEFORE THE WATER QUALITY APPEALS BOARD

DEPARTMENT OF ADMINISTRATION IN AND FOR THE STATE OF ARIZONA

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Appellant,                                                          )                              CASE NO.            _

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vs.                                                                       )                              NOTICE OF APPEAL

) DEPARTMENT OF ENVIRONMENTAL ) QUALITY,                                                        )

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)

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Respondents.                                                         )

                                                                          )

1.        The appellant files this Notice of Appeal with the Department of Environmental Quality according to A.R.S. § 49-323.

2.        Under A.R.S. § 49-323 and A.A.C. R2-17-101 et seq., if you, a Respondent in this case, have an interest in the final decision that may result from this Notice of Appeal, you are required to file an Answer to this Notice of Appeal within 20 days from the date of service of this Notice of Appeal on you.

3.        The name, address, and telephone number of the appellant is: Name:

Address: Telephone:

If I, the appellant, am represented by an attorney, the name, address, telephone number, and Arizona Bar number of my attorney is: Name:

Address:

Telephone:                                                   Bar No.

4.        The following is a list of names, mailing addresses, and telephone numbers of all of the following interested parties:

a.              The permittee, if the permittee is not the appellant;

b.              All persons who filed a notice of appearance in the action before the Department of Environmental Quality that the appel- lant is appealing; and

c.              The Department of Environmental Quality. Name:

Address:

Telephone:

Name: Address:

Telephone:

Name: Address:

Telephone:

5.        The specific action of the Department of Environmental Quality which is the basis of this appeal is the following: a.

b.

6.        The date of the action complained of in the previous paragraph (5) is (month) (day), (year).

7.        The date the appellant received notice of the action complained of in the previous paragraph (5) is (month) (day), (year).

8.        I request the relief below for the following reasons:

DATED (month) (day), (year)

Signature of the Appellant or the attorney for the Appellant

VERIFICATION

I verify that I have served or caused to be served a copy of this Notice of Appeal on the Department of Environmental Quality and all the persons listed in paragraph (4) above.

DATED (month) (day), (year)

Signature of the Appellant or the attorney for the Appellant

Historical Note

Adopted effective January 8, 1998 (Supp. 98-1).