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ATTACHMENT A "" -0 <br /> CALIFORNIA REGIONAL WATER QUALITY CONTROL BOARD <br /> CENTRAL VALLEY REGION <br /> NOTICE OF INTENT <br /> TO COMPLY WITH THE TERMS OF <br /> GENERAL WASTE DISCHARGE REQUIREMENTS ORDER NO. R5-2008-0149 <br /> IN-SITU GROUNDWATER REMEDIATION AT SITES WITH VOLATILE ORGANIC <br /> COMPOUNDS,NITROGEN COMPOUNDS, PERCHLORATE, PESTICIDES, <br /> SEMI-VOLATILE COMPOUNDS AND/OR PETROLEUM HYDROCARBONS <br /> 1. RESPONSIBLE PARTY INFORMATION <br /> Owner Name: <br /> Mailing Address: <br /> City/Locale: County: State: Zip: Telephone Number: <br /> Operator Name (if different than above): <br /> Mailing Address: County: State: Zip: Telephone Number: <br /> Contact Person: Title: Telephone Number: <br /> Owner Type: <br /> check one Individual ❑ Corporation ❑ Partnership ❑ Other: <br /> 2. TREATMENT SITE INFORMATION <br /> Site Name: <br /> Physical Address: <br /> City/Locale: County: State: Zip: Telephone Number: <br /> 3. LOCATION OF FACILITY <br /> Assessor's Parcel#: Closest Surface Water: (e.g. Sacramento River) <br /> Township/Range/Section: <br /> T R S B&M <br /> 4. REASON FOR FILING <br /> ❑ New Pilot Study ❑ Changes in Ownership/Operator <br /> ❑ New Full-Scale Treatment <br /> ❑ Other <br /> ❑ Update Plot Study <br /> ❑ Update Full-Scale Tretament <br /> 5. LOCAL PERMITS <br /> Has an agency issued permits or other entitlements(e.g., conditional use permit, building permit, hazardous <br /> materials storage permit, air permit, well permit)for the site? ❑ Yes ❑ No <br /> For each permit or entitlement, list the type, issuing agency, and date of issuance: <br />