1. NOTICE OF TERMINATION
      2. NOTICE OF TERMINATION (“NOT”) COMPLETENESS REVIEW
      3. AND FIELDWORK CHECKLIST FOR
      4. POST-NOVEMBER 19, 2010 PERMIT SUBMISSIONS

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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:

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Notice of Termination
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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.

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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)

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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
co-permittee 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

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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.
P age
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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