NOTICE OF TERMINATION

Transcription

1 NOTICE OF TERMINATION For Official Use Only State of Georgia Environmental Protection Division To Cease Coverage Under General Permit To Discharge Storm Water Associated With Construction Activity I. Permit Type: (Choose Only One) GAR Stand Alone GAR Infrastructure GAR 10003Common Development II. SITE / PERMITTEE INFORMATION Site/Project Name: GPS Location of Construction Exit: Site Location and Street Address: City: Subdivision Name: Owner s Name: County: Lot Number: Operator s Name: Type of Permittee: Primary Secondary Tertiary Facility Contact: If Applicable: Primary Permittee's Name: Number of Secondary Permittees: III. SITE ACTIVITY INFORMATION Construction Activity Completed No Longer Owner / Operator of Construction Activity Construction Activity: Commercial Industrial Municipal DOT Utility Residential Primary Permittee of a Subdivision Development, or Individual Lot, or Individual Lot within a Surface Water Drainage Area where the Primary Permittee has ceased Permit Coverage Name of Initial Receiving Water(s): Name of Municipal Storm Sewer System Owner/Operator: Name of Receiving Waters:

2 IV. CERTIFICATIONS. (Owner or Operator or both to initial as applicable.) 1. I certify under penalty of law that either: (a) all storm water discharges associated with construction activity from the portion of the construction activity where I was an Owner or Operator have ceased or have been eliminated; (b) all storm water discharges associated with construction activity from the identified site that are authorized by General NPDES Permit number indicated in Section I of this form have ceased; (c) I am no longer an Owner or Operator at the construction site and a new Owner or Operator has assumed operational control for those portions of the construction site where I previously had ownership or operational control; and/or if I am a primary permittee filing this Notice of Termination under Part VI.A.2. of this permit, I will notify by written correspondence to the subsequent legal title holder of any remaining lots that these lot Owners and /or Operators will become tertiary permittees for purposes of this permit and I will provide these tertiary permittees with the primary permittee s Erosion, Sedimentation and Pollution Control Plan. I understand that by submitting this Notice of Termination, that I am no longer authorized to discharge storm water associated with construction activity by the general permit, and that discharging pollutants in storm water associated with construction activity to waters of Georgia is unlawful under the Georgia Water Quality Control Act and the Clean Water Act where the discharge is not authorized by a NPDES permit. 2. I certify under penalty of law 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 gather and evaluate the information submitted. Based upon 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 am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Owner's Printed Name: Signature: Title: Date: Operator's Printed Name: Signature: Title: Date:

3 Instructions Notice of Termination (NOT) For Storm Water Discharges Associated With Construction Activity Who must file a Notice of Termination (NOT) Form NPDES General Permit This Notice of Termination must be typed. Any NOT that contains illegible information will not be accepted. All information on this NOT must be submitted to be a valid Notice. Any information requested on the NOT that is not applicable to the owner or operator or the site must be marked N/A. When the facility/site has been finally stabilized and all storm water discharges from construction activities authorized by the NPDES General Permit number indicated in Section I of this form have ceased or when the Owner/Operator of the site changes, the Owner/Operator of the facility/site must submit a Notice of Termination (NOT). Final Stabilization means that all soil disturbing activities at the site have been completed, and that for unpaved areas and areas not covered by permanent structures, 100% of the soil surface is uniformly covered in permanent vegetation with a density of 70% or greater, or equivalent permanent stabilization measures (such as the use of rip rap, gabions, permanent mulches or geotextiles) have been used. Permanent vegetation shall consist of: planted trees, shrubs, perennial vines; a crop of perennial vegetation appropriate for the time of year and region; or a crop of annual vegetation and a seeding of target crop perennials appropriate for the region. Final stabilization applies to each phase of construction Where to file NOT Forms - The NOT and attachments must be sent to the Regional Office or District Office shown on the next page. Please submit only the first two pages of this document plus your attachments, if necessary. Section I. Permit Type - Indicate the NPDES General Permit number for which this form is being submitted. Section II. Site / Permittee Information Enter the information required. The site/project name is the physical location of the construction activity. Should the site lack a street address, sufficiently describe the facility location so that it can be found by district personnel. Should additional space be needed, attach the description to the notice. The facility contact is the person who the Owner and Operator has assigned the responsibility for the daily on-site operational control. Please do not leave any blanks in this section. Section III. Site Activity Information Indicate by marking the appropriate block whether this NOT is submitted due to completion of the construction activity or a change in the Owner and Operator of the construction activity. Mark the appropriate box to indicate the class of construction activity that was conducted at the site. For residential sites, also mark the block as either a subdivision development or an individual lot. Section IV. Certifications All applicants must sign this Notice. Permittees shall initial next to the applicable certification statements on the line provided. Federal and State statutes provide specific requirements as to whom is authorized to sign Notice of Terminations. Signing of a Notice of Termination by others is not a valid submittal. Please be aware Federal and State statues provide severe penalties for submitting false information on this application form. Federal and State regulations require this application to be signed as follows: - For a corporation: by a responsible corporate officer; - For a partnership or sole proprietorship: by a general partner or the proprietor; or - For a municipality, state, Federal or other public facility: by either a principal executive officer or ranking elected official.

4 GEORGIA EPD DISTRICT OFFICES All Notice of Intents, Notice of Terminations, Erosion, Sedimentation and Pollution Control Plans, Comprehensive Monitoring Programs, certifications, reports, and any other information shall be sent to the following District offices of EPD: A. For facilities/sites located in the following counties: Bibb, Bleckley, Chattahoochee, Crawford, Dooly, Harris, Houston, Jones, Lamar, Macon, Marion, Meriwether, Monroe, Muscogee, Peach, Pike, Pulaski, Schley, Talbot, Taylor, Troup, Twiggs, Upson West Central District Office 2640 Shurling Drive Macon, GA (478) B. For facilities/sites located in the following counties: Burke, Columbia, Emanuel, Glascock, Jefferson, Jenkins, Johnson, Laurens, McDuffie, Montgomery, Richmond, Screven, Treutlen, Warren, Washington, Wheeler, Wilkinson East Central District Office 1885-A Tobacco Road Augusta, GA (706) C. For facilities/sites located in the following counties: Baldwin, Banks, Barrow, Butts, Clarke, Elbert, Franklin, Greene, Hall, Hancock, Hart, Jackson, Jasper, Lincoln, Madison, Morgan, Newton, Oconee, Oglethorpe, Putnam, Stephens, Taliaferro, Walton, Wilkes Northeast District Office 745 Gaines School Road Athens, GA (706) D. For facilities/sites located in the following counties: Clayton, Coweta, DeKalb, Fayette, Gwinnett, Heard, Henry, Rockdale, Spalding Mountain District - Atlanta Satellite 4244 International Parkway, Suite 114 Atlanta, GA (404) E. For facilities/sites located in the following counties: Bartow, Carroll, Catoosa, Chattooga, Cherokee, Cobb, Dade, Dawson, Douglas, Fannin, Floyd, Forsyth, Fulton, Gilmer, Gordon, Habersham, Haralson, Lumpkin, Murray, Paulding, Pickens, Polk, Rabun, Towns, Union, Walker, White, Whitfield Mountain District - Cartersville Office P.O. Box 3250 Cartersville, GA (770) F. For facilities/sites located in the following counties: Appling, Atkinson, Bacon, Brantley, Bryan, Bulloch, Camden, Candler, Charlton, Chatham, Clinch, Coffee, Effingham, Evans, Glynn, Jeff Davis, Liberty, Long, McIntosh, Pierce, Tattnall, Toombs, Ware, Wayne Coastal District- Brunswick Office One Conservation Way Brunswick, GA (912)

5 G. For facilities/sites located in the following counties: Baker, Ben Hill, Berrien, Brooks, Calhoun, Clay, Colquitt, Cook, Crisp, Decatur, Dodge, Dougherty, Early, Echols, Grady, Irwin, Lanier, Lee, Lowndes, Miller, Mitchell, Quitman, Randolph, Seminole, Stewart, Sumter, Telfair, Terrell, Thomas, Tift, Turner, Webster, Wilcox, Worth Southwest District Office 2024 Newton Road Albany, GA (912)