1. PAG-15
      2. COMMONWEALTH OF PENNSYLVANIA FROM THE
      3. APPLICATION OF PESTICIDES
      4. NOTICE OF TERMINATION OF COVERAGE FORM

3800-PM-BPNPSM0345e 8/2012
Applicant Name:
Notice of Termination
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 violations of the Clean Water Act and the Clean Streams Law.
Signature/Responsible Official:
Date:
Title:
Printed Name:

Back to top