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Pollutant 1

Pollutant 2

Pollutant 3

Add Columns and/or tables as needed

Lowest Reporting Limit

Highest Reporting Limit

Number of Samples with Lowest Reporting Limit

Sample Date 1, Method Number

Sample Date 2, Method Number

Sample Date 3, Method Number

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12.

Any other relevant information about this project that may be necessary to evaluate the eligibility of this discharge under the Order is included in Attachment 6.

13.

Add the following five attachments to this form:

Attachment 1: Flow Schematics

Attachment 2: Engineering Certification Report

Attachment 3: Aerial Map (highlight the discharge path)

Attachment 4: Check for $5,688

Attachment 5: Tables listing Pollutants of Concern at this Site

Attachment 6: Other Information (If applicable)

Note: The Regional Water Board may modify this form at any time to reflect any new fees and other needed improvements as applicable.

Attachment B – Notice of Intent FormB-7

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

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