1. PAG-15NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
      1. B. Operator Information:
      2. D. Certification:

3800-PM-BPNPSM0345e 8/2012  Applicant Name:
Notice of Te rmination    Permit No.:
 
 

COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT



PAG-15
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)

GENERAL PERMIT FOR POINT SOURCE DISCHARGES TO WATERS OF THE
COMMONWEALTH OF PENNSYLVANIA FROM THE
APPLICATION OF PESTICIDES

NOTICE OF TERMINATION OF COVERAGE FORM


 

A. NPDES Permit Number:      

 


 
B. Operator Information:
Name:      
Mailing Address:      
Street Address:      
City:      County:     State:     Zip Code:     
Contact Person:      Title:     
Telephone:      Email:     

 

C. Basis for Termination (check one only)

 

A new Operator (Decision-Maker) has taken over responsibility for the pest treatment.
You have ceased aquatic pesticide application for which you obtained permit coverage or there will no longer be a pesticide discharge.
Permit coverage has been obtained under an individual or alternative General Permit for all pesticide discharges requiring NPDES permit coverage either because DEP required such coverage or you petitioned DEP requesting coverage under an individual or alternative permit.

 


D. Certification:

 

I certify under penalty of law and subject to the penalties of 18 Pa. C.S. Section 4904 (relating to unsworn falsification to authorities) that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I further acknowledge that the facility, treatment area and operator described herein is eligible for coverage under DEP’s General Permit. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Additionally, I understand that the submittal of this Notice of Termination does not release a pesticide applicator from liability for any viol ations of the Clean Water Act and the Clean Streams Law.
 

Signature/Responsible Official: Date:     

 

Title:      

 

Printed Name:      

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