1. APPENDIX A
  2. APPENDIX B
  3. APPENDIX C
  4. NOTICE OF TERMINATION (“NOT”) COMPLETENESS REVIEW

3800-PM-BCW0229b 7/2017
Notice of Termination
 
 
 
 
3800-PM-BCW0229b 7/2017
Notice of Termination
 
3800-FM-BCW0229b 7/2017
Notice of Termination
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER
OFFICIAL USE ONLY
 
PA  
 
NOTICE OF TERMINATION
FOR A GENERAL (PAG-02) OR INDIVIDUAL NPDES PERMIT, ESCP, or   ESCGP

FOR STORMWATER DISCHARGES ASSOCIATED WITH   CONSTRUCTION ACTIVITIES

PLEASE READ THE NOTICE OF TERMINATION INSTRUCTIONS PROVIDED WITH THIS NOTICE OF TERMINATION FORM BEFORE COMPLETING THIS FORM AND THE ATTACHED CHECKLIST.
PLEASE PRINT OR TYPE INFORMATION IN BLACK OR BLUE INK.

Applicability: A permittee(s) presently covered under an Individual National Pollutant Discharge Elimination System (NPDES) Permit for Stormwater Discharges Associated with Construction Activities, the General NPDES Permit for Stormwater Discharges Associated with Construction Activities (PAG-02), an Erosion and Sediment Control Permit (ESCP), or an Erosion and Sediment Control General Permit for Earth Disturbance Associated with Oil and Gas Exploration, Production, Processing, or Treatment Operations or Transmission Facilities (ESCGP) shall submit this notice of Termination (NOT) form to the Department of Environmental Protection (Department) or delegated conservation district for permit applications submitted after November 19, 2010 .
1.   PERMIT INFORMATION:

Check the appropriate box.

NPDES Stormwater Construction Permit #        

Erosion and Sediment Control Permit #        

Erosion and Sediment Control General Permit #        

2.   PROJECT LOCATION OR PHYSICAL ADDRESS:

Facility/Development Name:        

Address:        

Municipality:           County:        

Latitude:           ° /           ' /           "   Longitude:           ° /           ' /           "

3.   REASON FOR PERMIT TERMINATION:

Check the appropriate box.

  Full Permit Termination – all planned activities were conducted and are complete, and the entire site is encompassed by this NOT

  Full Permit Termination – some planned activities were conducted, and the entire site is encompassed by this NOT

    Full Permit Termination – no planned activities were conducted, and the entire site is encompassed by this NOT

  Partial Permit Termination – all planned work is complete for a portion of the site, described as
        , encompassed by this NOT

 

4.   PERMITTEE(S) INFORMATION:

PERMITTEE   PERMITTEE (additional)

Name:           Name:        

Address:           Address:        

City:           City:        

State:           Zip Code:           State:           Zip Code:        

Telephone Number:           Telephone Number:        
Email Address:           Email Address:        

5.   FINAL CERTIFICATION OF LICENSED PROFESSIONAL:

This section is to be completed by a licensed professional as defined in 25 Pa. Code §102.1.
I,           , do hereby certify pursuant to the penalties of 18 Pa. C.S.A. § 4904 to the best of my knowledge, information and belief, that the accompanying record drawings accurately reflect the as-built conditions, are true and correct, and are in conformance with Chapter 102 of the rules and regulations of the Department of Environmental Protection and that the project site was constructed in accordance with the approved PCSM Plan or Site Restoration/Reclamation plan, all approved plan changes and accepted construction practices.

Name and Official Title of Licensed Professional

       

       

Signature:  

 

Licensed

Professional

Seal

 
6.  LONG-TERM OPERATION AND MAINTENANCE AND RESTORATION/RECLAMATION:

This project involves: (check the appropriate box)

-  Installation or utilization, and subsequent long-term operation and maintenance of PCSM BMPs per 25 Pa. Code §102.8(a) through (m).

OR

-  Installation of PCSM BMPs identified as restoration or reclamation activities per 25 Pa. Code §102.8(n).

Note: For projects solely involving restoration or reclamation activities, proceed to Section 8.

 

7.  PROOF OF INSTRUMENT FILING WITH THE RECORDER OF DEEDS OFFICE:

Per 25 Pa. Code §102.8(m)(2), the instrument will assure disclosure of the PCSM BMP(s) and the related obligations in the ordinary course of a title search of the subject property. The recorded instrument must identify the PCSM BMP(s), provide for the necessary access related to long-term operation and maintenance of the PCSM BMP(s) and provide notice that the responsibility for long-term operation and maintenance of the PCSM BMP(s) is a covenant that runs with the land that is binding upon and enforceable by subsequent grantees. A long-term operation and maintenance plan shall be recorded along with the instrument.

For either Commonwealth or federally-owned property, a covenant that runs with the land is not required until the transfer of the land containing the PCSM BMP(s) occurs. Upon said transfer, the deed must then comply with 25 Pa. Code § 102.8(m)(2).
a.  Is the project located entirely on Commonwealth or federally-owned property? Yes No
 
If the answer to question a., above, is Yes, proceed to Section 8.
 
If the project is not located entirely on Commonwealth or federally-owned property, proceed to Section 7.b. The completed Section 7.b and an attached copy of the Recorder of Deeds Office receipt constitutes proof of instrument filing as required by 25 Pa. Code §102.7(b)(5).
 
Also attach copies of the “landowner notice(s)” provided to all landowners who have bought or accepted ownership or other legal responsibility for parcels within the permit boundary.
 
b.
 

I certify, under penalty of law, that the below checked items have been recorded at the project county’s Recorder of Deeds Office to assure disclosure of the PCSM BMP(s) and the related obligations in the ordinary course of a title search of the subject property, and which meet the requirements of 25 Pa. Code §102.8(m)(2).

 Legal instrument which addresses 25 Pa. Code §102.8(m)(2) (required)

 Record drawings which accurately reflect as-built conditions (required)

 Long-term operation and maintenance plan which clearly outlines the operation and maintenance activities necessary for the associated PCSM BMP(s) (required)

 Long-term operation and maintenance agreement(s) (required if any individual other than the permittee is identified in Appendix C as being responsible for the long-term operation and maintenance of one or more PCSM BMPs)

 

8.  Permit Termination Certification:
This Section is to be completed by the person(s) listed in Section 4.
 
I,          , certify under penalty of law that either permanent stabilization, under 25 Pa. Code §102.22(a)(2), of the earth disturbance activities has occurred or the site has been returned to agricultural operation regulated under 25 Pa. Code §102.4(a). I certify under penalty of law that either the installation of BMPs in accordance with an approved plan* prepared and implemented per §§ 102.4 and 102.8 (relating to erosion and sediment control requirements; and PCSM requirements) has occurred or all approved restoration/reclamation activities have been completed. I understand that by submitting this NOT, I am no longer authorized to conduct earth disturbance activities under the referenced permit and that discharging stormwater from earth disturbance activities to waters of the Commonwealth is unlawful where the discharge is not authorized by a permit. I also understand that the submittal of this NOT does not release a permittee or copermittee from liability for any violations of the permit, the federal Clean Water Act (if applicable), the Pennsylvania Clean Streams Law and the rules and regulations promulgated thereunder, or from liability for any environmental damages occurring as a result of any earth disturbance activities conducted at the site. I understand that there are significant penalties for submitting false information, including possible fines and imprisonment for knowing violations.
*Upon NOT approval, the submitted record drawings or site restoration/reclamation plan equates an approved plan.
 

 Individual; proceed to signature portion.

 

I hereby certify that I am the signatory pursuant to 25 Pa. Code § 92a.22 and 40 CFR §122.22 and that I am the person who is responsible for decision-making regarding environmental compliance functions for Enter Entity name, the manager of one or more manufacturing, production, or operating facilities of the permittee and am authorized to make management decisions which govern the operation of regulated facility including having explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure the permittee’s long term environmental compliance with environmental laws and regulations.

(choose one of the following; not applicable for individuals):

president vice president secretary treasurer

of           Corporation/Company
   Entity name

member or manager of           LLC
   Entity name

 general partner of             partnership/LP/LLP
   Entity name

 principal executive officer or ranking elected official of           Municipality/State/Federal/other public agency
 Entity name

 Power of Attorney/delegation of contractual authority (documentation supporting delegation of contracting authority must be provided) for          

   Entity name
 

SIGNATURE

   Permittee
         

 Print Name and Title of Person Signing
   

 Signature of Permittee
          

  Date Signed

   

 

APPENDIX A
Summary Table of Installed PCSM BMPS
Check all applicable PCSM BMPS that have been installed as part of the approved PCSM Plan along with their associated function(s).
Note: VC = Volume Control, RC = Rate Control and WQ = Water Quality
 

Permit No.:        
 

BMP
Function(s)
No. of BMPs
Total Acres
Treated
Total Volume Treated
 
Wet Ponds
  VC   RC   WQ
     
     
     
  Constructed Wetlands   VC   RC   WQ
     
     
     
  Retention Basins   VC   RC   WQ
     
     
     
  Detention Basins   VC   RC    
     
     
     
  Underground Detention   VC   RC    
     
     
     
  Dry Extended Detention Basin   VC   RC    
     
     
     
  Sediment Fore Bay   VC       WQ
     
     
     
  Infiltration Trench   VC   RC   WQ
     
     
     
  Infiltration Berm/Retentive Grading   VC   RC   WQ
     
     
     
  Subsurface Infiltration Bed   VC   RC   WQ
     
     
     
  Infiltration Basin   VC   RC   WQ
     
     
     
  Pervious Pavement   VC   RC   WQ
     
     
     
  Dry Well/Seepage Pit   VC   RC   WQ
     
     
     
  Bio-Infiltration Areas   VC   RC   WQ
     
     
     
  Rain Gardens/Bio-Retention   VC   RC   WQ
     
     
     
  Vegetated Swales   VC   RC   WQ
     
     
     
  Constructed Filters   VC   RC   WQ
     
     
     
  Protect Sensitive & Special Value Features   VC   RC   WQ
     
     
     
  Protect/Convert/Establish Riparian Buffers   VC   RC   WQ
     
     
     
  Restoration: Buffers/Landscape/Floodplain   VC   RC   WQ
     
     
     
  Disconnection From Storm Sewers   VC   RC   WQ
     
     
     
  Rooftop Disconnections   VC   RC   WQ
     
     
     
  Vegetated Roofs   VC   RC   WQ
     
     
     
  Runoff Capture/Reuse   VC   RC   WQ
     
     
     
  Oil/Grit Separators           WQ
     
     
     
  Water Quality Inserts/Inlets           WQ
     
     
     
  Street Sweeping           WQ
     
     
     
  Soil Amendment/Soil Restoration   VC   RC   WQ
     
     
     
  Other         VC   RC   WQ
     
     
     
  Other         VC   RC   WQ
     
     
     
  Other         VC   RC   WQ
     
     
     
 

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APPENDIX B
Record Drawings (accurately reflecting as-built conditions) Checklist

 

Permit No.:        

Indicate whether each item is included or not applicable  
  Building Improvements
Included
Not Applicable
Item
 
 
 
 
 
 
 
Building Footprint
 
 
 
 
 
 
 
Limits of Paving and other impervious areas
 
 
 
 
 
 
 
Property Lines
 
 
 
 
 
 
 
Finish Grading
 
 
 
 
 
 
 
Downspout Locations
Site Utilities
Included
Not Applicable
Item
 
 
 
 
 
 
 
Well location
 
 
 
 
 
 
 
Septic tanks, dosing tanks, distribution boxes and on-lot absorption area
Stormwater Conveyance
Included
Not Applicable
Item
 
 
 
 
 
 
 
Pipe locations including pipe material, diameter, slope and length
 
 
 
 
 
 
 
Inlets and endwall locations including inverts and grate elevations
 
 
 
 
 
 
 
Swale locations and dimensions
 
 
 
 
 
 
 
Rock aprons and other pipe outlets locations
Post Construction Storm Water Management (PCSM)
Included
Not Applicable
Item
 
 
 
 
 
 
 
Structural PCSM BMP locations and access
 
 
 
 
 
 
 
Non-Structural PCSM BMP locations
 
 
 
 
 
 
 
Construction details of PCSM BMPs in as-built condition
 
 
 
 
 
 
 
BMP berm elevations
 
 
 
 
 
 
 
BMP bottom elevations
 
 
 
 
 
 
 
Emergency spillway elevation
 
 
 
 
 
 
 
Emergency spillway length
 
 
 
 
 
 
 
Emergency spillway protection (TRW, Riprap, etc.)
 
 
 
 
 
 
 
Outlet structure elevations, orifice sizes
 
 
 
 
 
 
 
Pipe size, length, material, elevations and slope
 
 
 
 
 
 
 
Show all rain barrels, seepage pits, infiltration trenches
 
 
 
 
 
 
 
Show limits (soil amendments, new wood line, etc.)
 
 
 
 
 
 
 
Cover condition (lawn, meadow, woods, etc.)
 
 
 
 
 
 
 
PCSM BMP Long-Term O&M
PCSM – Irrigation BMPs only
Included
Not Applicable
Item
 
 
 
 
 
 
 
Spray Head and Valve Locations and Spray Radii
 
 
 
 
 
 
 
Pump Location
 
 
 
 
 
 
 
Pump Information (Duty point, HP)
 
 
 
 
 
 
 
Controller Location
 
 
 
 
 
 
 
Intake Location
 
 
 
 
 
 
 
Location of main (size and material)
 
 
 
 
 
 
 
Laterals (size and material)
 
 
 
 
 
 
 
Dosing Schedule
 
 
 
 
 
 
 
Drip Field with tubing location  

 

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APPENDIX C

Permit No.:        

Person(s) Responsible for Long-Term Operation and Maintenance of PCSM BMPs:
 
Statement : The following individual(s) understand and have agreed to the long-term operation and maintenance of the PCSM BMPs as per the long-term operation and maintenance plan.
PCSM BMPs (list one BMP per row)
Latitude and Longitude, of each
PCSM BMP
Name of Responsible Party
Address
Phone #
           
     
           
           
     
           
           
     
           
           
     
           
           
     
             

Attach additional Appendix C Forms as needed.   Page       of      
 

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NOTICE OF TERMINATION (“NOT”) COMPLETENESS REVIEW
AND FIELDWORK CHECKLIST FOR

POST-NOVEMBER 19, 2010 PERMIT SUBMISSIONS


 

Facility/Development Name:           Permit No.:        

C = Complete, NC = Not Complete, N/A = Not Applicable

Paperwork Requirements:

SECTION 1 - NON-COMMONWEALTH/NON-FEDERAL PROPERTY
Permittee Included
Reviewer
Item
  C
NC
 
     
Completed Sections 1-8 of the NOT
     
Record Drawings which accurately reflect as-built conditions
     
Copy of Recorder of Deeds Office receipt for instrument filing
  N/A   N/A  
Copy of Landowner Notices (required if sale or other transfer of any parcel, lot, road, or other real property occurred within the permit boundary during the life of the permit)
     
Completed Appendices A, B, and C
SECTION 2 - COMMONWEALTH/FEDERAL PROPERTY
Permittee Included
Reviewer
Item
  C
NC
 
     
Completed Sections 1-7.a. and 8 of the NOT
     
Record Drawings which accurately reflect as-built conditions
     
Completed Appendices A and B  
SECTION 3 - RESTORATION/RECLAMATION ACTIVITY
Permittee Included
Reviewer
Item
  C
NC
 
     
Completed Sections 1-6 and 8 of the NOT
     
Record Drawings or Site Restoration/Reclamation Plan
 

Fieldwork Requirements :

SECTION 4 - FIELD INSPECTION (Required for permit termination)
Permittee Addressed
Reviewer
Item
  C
NC
 
     
Permanent Stabilization per 25 Pa. Code §102.22(a)(2)

or the return to agricultural operation regulated under 25 Pa. Code §102.4(a)

  N/A
  N/A  
Installation of PCSM BMPs per 25 Pa. Code §102.8(a) through (m) and approved permit (required for non-restoration/reclamation activities)
  N/A
  N/A  
Installation of PCSM BMPs per 25 Pa. Code §102.8(n) and approved permit (required for restoration/reclamation activities)
     
Removal of E&S BMPs per 25 Pa. Code §102.22(a)(1) and approved permit
 

OFFICIAL USE ONLY

Determination:   Approve   Deny   Inspection Report No:        

Reviewer Name:           Date:        

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