3800-PM-BCW0229a 7/2017
    Notice of Termination
     
    3800-PM-BCW0229a 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.

    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 permits granted the grandfathering provision per 25 Pa. Code §102.8(a).
    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) SUBMITTING THIS NOTICE OF TERMINATION:

     

    PERMITTEE   PERMITTEE (additional)

    Name:           Name:        

    Address:           Address:        

    City:           City:        

    State:           Zip Code:           State:           Zip Code:        

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

     

    5.   CERTIFICATION (To be completed by person(s) listed in Section 4):

    I certify under penalty of law that all discharges associated with earth disturbance activities at the site that are authorized by the NPDES permit, an Erosion and Sediment Control Permit, or an Erosion and Sediment Control General Permit (ESCGP) identified in Section 1 above have been eliminated, and either the site has been stabilized and Post Construction Stormwater Management BMPs have been installed or the site has been returned to agricultural operation regulated under 25 Pa. Code §102.4(a) . I understand that by submitting this Notice of Termination, I am no longer authorized to conduct earth disturbance activities under the above referenced permit, and that discharging stormwater from construction activities to waters of the Commonwealth is unlawful where the discharge is not authorized by a permit. I also understand that the submittal of the Notice of Termination does not release a permittee from liability for any violations of this permit or of the federal Clean Water Act, the Pennsylvania Clean Streams Law and the regulations promulgated pursuant thereto or from liability for any environmental damages occurring as a result of any earth disturbance activities conducted at the site. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

     

    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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