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ATTACHMENT A *ME -"go, -2- INSTRUCTIONS 2- INSTRUCTIONS FOR COMPLETING THE NOTICE OF INTENT TO COMPLY WITH GENERAL ORDER NO.R5-2008-0149 FOR IN-SITU GROUNDWATER REMEDIATION IN-SITU GROUNDWATER REMEDIATION AT SITES WITH VOLATILE ORGANIC COMPOUNDS,NITROGEN COMPOUNDS,PERCHLORATE,PESTICIDES, SEMI-VOLATILE COMPOUNDS AND/OR PETROLEUM HYDROCARBONS 4. REASON FOR FILING Check the appropriate box or boxes. 5. LOCAL PERMITS Construction and operation of some types of facilities usually involves permits or entitlements from a local agency, such as a City or County. These permits or entitlements may include discretionary or ministerial permits such as conditional use permits, hazardous waste storage permits, air permits, well permits, and building permits. Documents and information should be available from the issuing agency, in most cases the City/County planning department. For each permit or entitlement, identify the issuing agency,the date of issuance, and provide a copy of associated documentation. 6. CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) Compliance with the California Environmental Quality Act(CEQA) is required prior to enrollment under the General WDRs. The CEQA lead agency must either determine that your project is exempt from CEQA, or must prepare an environmental document (either an Environmental Impact Report, Mitigated Negative Declaration, or Negative Declaration). Has a public agency made a CEQA determination for the facility? If YES, give the name, date, and type of determination (This could be a Notice of Exemption,Notice of Determination,Negative Declaration, etc.). Enclose a copy of the CEQA documentation. If NO, fill in the expected type and date of completion. For the date of completion, list the date that the CEQA documentation will be completed. If not known, write "Unknown". 7. PROCESS Provide summary information here. Much of the descriptive and technical information will be submitted to comply with the information needs specified in Attachment B. 8. WASTES GENERATED Check all types of wastes that exist at your facility. 9. AMENDMENT STORAGE Provide the requested information, and attach additional sheets as necessary. An above ground or underground tank may be used to contain the amendments; in either case, the tank must be constructed of materials suitable for the intended use. 10. CERTIFICATION Certification by the operator of the facility is required. The appropriate person must sign the application form. Acceptable signatures are: a. For a corporation, a principal executive officer of at least the level of senior vice-president; b. For a partnership or individual (sole proprietorship), a general partner or the proprietor;