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I certify under penalty of law that this document and all attachments are prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted.  Based on my inquiry of the design engineer whose signature and engineering license number is documented in this notice, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.  I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

___________________________       ____________________________________

Name (print)Signature and Date

___________________________       ____________________________________

Title/OrganizationAddress

Complete Table 2.  Facility Information

1

Discharger’s Name

2

Name of Facility

3

Facility Address

4

Facility Contact, Title, and Phone

5

Authorized Person to Sign & Submit Reports

6

Mailing Address

7

Billing Address

8

Type of site or project.  For example: Active Service Station, Closed Service Station, Short Term Dewatering Project, Long Term Dewatering Project, or other (please explain if “Other”)

Attachment B – Notice of Intent FormB-2

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

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