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'%MW ..i ATTACHMENT A CALIFORNIA REGIONAL WATER QUALITY CONTROL BOARD CENTRAL VALLEY REGION INSTRUCTIONS 401 FOR COMPLETING THE NOTICE OF INTENT TO COMPLY WITH THE TERMS OF GENERAL WASTE DISCHARGE REQUIREMENTS ORDER NO. R5-2008-0149 FOR IN-SITU GROUNDWATER REMEDIATION AT SITES WITH VOLATILE ORGANIC COMPOUNDS,NITROGEN COMPOUNDS, PERCHLORATE, PESTICIDES, SEMI-VOLATILE COMPOUNDS AND/OR PETROLEUM HYDROCARBONS N81 The Notice of Intent is to be submitted by responsible parties that elect to obtain coverage under the above General Order. If you have any questions regarding the completion of any part of the following form, please contact your Regional Board representative, as described on page 4. Much of the information needed to complete this form may be available from County Use Permit engineering reports or county records. Any additional information supplied, as detailed in Attachment B, should be included on attached sheets and list all attachments with the titles and dates in the spaces provided. 1. RESPONSBILE PARTY INFORMATION You must provide the information listed below for ALL persons or entities that hold legal interests associated with the facility or real property on which it is located. These may include, but are not limited to, owners, leaseholders, lessees, and operators. Under Owner Name/Address, include the legal name of the business entities and/or persons who own the facility undergoing remedial activities,the owner's mailing address, and phone number. Under Operator Name, include the name of the business entities or persons who actually operate the facility only if different than the owner. Under Mailing Address, include the mailing address where legal notices may be received by the operator if it is different form the physical facility address. You may specify another contact person at the mailing address if desired. Check the appropriate Owner type. Both the Owner and the Operator will be named in the Notice of Applicability and will receive legal notices and invoices at these addresses. 2. TREATMENT SITE INFORMATION: Provide the Facility name,the physical address of the treatment location,the facility contact person (preferably a responsible employee with offices at the facility), and phone number at the facility. Do not use a P.O. Box number in this section. If there is no street address, use closest street and nearest cross street. 3. LOCATION OF FACILITY Enter the Assessor's Parcel Number(s) (APN). This number is located on the property tax bill and can also be obtained from the County Assessor's Office. Indicate the APN for both the facility and any land discharge areas owned by the Discharger. Specify the closest surface water body in the vicinity of the facility, such as a creek, canal, or river.