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ATTACHMENT B - NOTICE OF INTENT APPLICATION FORM

To Receive

Authorization to Discharge Treated Groundwater under the Requirements of
ORDER NO. R2-2006-XXXX
NPDES PERMIT NO. CAG912002 (FUEL)

For Groundwater Treatment Facility located at:

_________________________________________________________________

Type or Print Facility Address above the line

File No: 1210.44

This is an application for discharge or reuse of extracted and treated groundwater resulting from the cleanup of groundwater polluted by fuel leaks and other related wastes at service stations and similar sites.  Please mark one of the applicable lines:

Table 1. Mark only one as applicable

1

Notice of Intent for an Existing Discharge (for Permit Reissuance)

2

Notice of Intent for a previously regulated Discharge (provide the Order and NPDES permit numbers here in this row)

3

Notice of Intent for a New Discharge

4

Modified Notice of Intent (if modified, complete all sections in this Form and indicate information on which item(s) below are modified):

Discharger’s Certification

Administrative Information

Condition 1

Condition 2

Condition 3

Condition 4

Condition 5

Condition 6

Condition 7

Condition 8

Condition 9

Condition 10

Condition 11

Condition 12

Attachment 1

Attachment 2

Attachment 3

Attachment 4

Attachment 5

Discharger’s Certification

Attachment B – Notice of Intent FormB-1

Order No. R2-2006-0075, Fuel General NPDES Permit No. CAG912002

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