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Groundwater VOC and Fuel General Permit ORDER NO.R2-2012-0012 <br /> NPDES NO.CAG912002 <br /> ATTACHMENT B—NOTICE OF INTENT (NOI)APPLICATION FORM AND <br /> INSTRUCTIONS <br /> Complete and submit this NOI to apply for Authorization or Reauthorization to Discharge and/or <br /> reuse extracted and treated groundwater resulting from the cleanup of groundwater polluted by <br /> volatile organic compounds (VOC),fuel leaks, and other related waste under the requirements of <br /> NPDES Permit No. CAG912002 <br /> (VOC and Fuel General Permit) <br /> I certify under penalty of law that this document and all attachments are prepared under my direction or <br /> supervision in accordance with a system designed to assure that qualified personnel properly gathered <br /> and evaluated the information submitted. Based on my inquiry of the design engineer whose signature <br /> and engineering license number is documented in this notice, the information submitted is, to the best of <br /> my knowledge and belief,true, accurate, and complete. I am aware that there are significant penalties <br /> for submitting false information, including the possibility of a fine and imprisonment. <br /> Name(print) Signature and Date <br /> Title/Organization Address of Responsible Official <br /> This Application is for the Groundwater Treatment Facility located at (provide street address): <br /> This NOI form and all required attachment shall be uploaded to Geo-Tracker, <br /> http://www.waterboards.ca.gov/ust/electronic submittaUindex.shtml (contact Lourdes Gonzales at <br /> (510) 622-2365 or l�onzales(a�waterboards.ca.gov if you have any questions). If electronic submittal <br /> is not possible, applicants may submit the NOI package to the following address: California Regional <br /> Water Quality Control Board, San Francisco Bay Region, 1515 Clay Street, Suite 1400, Oakland, <br /> California 94612. Please include a check for$11,195 (as of December 2011), or the most current fee <br /> amount,payable to the State Water Resources Control Board. <br /> Table B-1. Mark onl one as a licable <br /> 1 This is a new discharge. <br /> This discharge is currentiy authorized under Order No.R2-2009-0059(VOC General Permit), <br /> 2 which requires authorized dischargers,who need to continue discharging after September 30,2014, <br /> to file a com leted NOI form no later than A ri13,2014. <br /> This discharge is currentty authorized under this Order(VOC and Fuel General Permit), <br /> 3 which requires authorized dischargers who need to continue discharging after January 11,2017,to <br /> file a com leted NOI form no later than Jul 15,2016. <br /> 4 This discharge is currently authorized under this Order(VOC and Fuel General Permit)and <br /> this Form is submitted for modification of the current Authorization to Dischar e. <br /> Attachment B—NOI Application FOrnl and InstnlCtiOns B-1 <br />