1. NOTICE OF TERMINATION

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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:

3800-PM-BCW0229a 7/2017
Notice of Termination
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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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