EPA_Form_3510-13.pdf

Construction General Permit (CGP)

Page K -1 of 4

Appendix K - Notice of Termination (NOT) Form and Instructions Part 8.3 requires you to use the electronic NOI system, or “eNOI” system, to prepare and submit your NOT. However, where your EPA Regional Office specifically authorizes you to use a paper NOT form, you are required to complete and submit the following form.

EPA Form 3510-13 Page 1 of 3

NPDES

FORM

3510-13

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, DC 20460

NOTICE OF TERMINATION (NOT) FOR STORMWATER DISCHARGES ASSOCIATED WITH

CONSTRUCTION ACTIVITY UNDER AN NPDES GENERAL PERMIT

Form Approved.

OMB No. 2040-0004

Submission of this Notice of Termination constitutes notice that the operator identified in Section II of this form is no longer authorized discharge pursuant to the NPDES Construction General Permit (CGP) from the site identified in Section III of this form. All necessary information must be included on this form. Refer to the instructions at the end of this form.

I. Approval to Use Paper NOT Form Have you been given approval from the Regional Office to use this paper NOT form*? YES NO

* Note: You must have been given approval by the Regional Office prior to using this paper NOT form.

II. Permit Information

NPDES Stormwater General Permit Tracking Number:

Reason for Termination (Check only one):

You have completed earth-disturbing activities at your site, and you have met all other requirements in Part 8.2.1.

Another operator has assumed control over all areas of the site and that operator has submitted an NOI and obtained coverage under the CGP.

You have obtained coverage under an individual permit or another general NPDES permit addressing stormwater discharges from the construction site.

III. Operator Information

Name:

IRS Employer Identification Number (EIN):

Mailing Address:

Street:

City:

State:

Zip Code: -

Phone: - -

Ext.

Fax (optional): - -

E-mail:

IV. Project/Site Information

Project/Site Name:

Project/Site Address:

Street/Location:

City:

State:

Zip Code: -

County or similar government subdivision:

V. Certification Information 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 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 am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

First Name, Middle Initial, Last Name:

Title:

Signature: Date: / /

Email:

Instructions for Completing EPA Form 3510-13

Notice of Termination (NOT) of Coverage Under an NPDES General Permit for Stormwater Discharges Associated with Construction Activity

NPDES Form Date (2/16) This Form Replaces Form 3510-13 (12/08) Form Approved OMB No. 2040-0004

EPA Form 3510-13 Page 2 of 3

Who May File an NOT Form Permittees who are presently covered under the EPA-issued 2012 Construction General Permit (CGP) for Stormwater Discharges Associated with Construction Activity may submit an NOT form when: (1) earth-disturbing activities at the site are completed and the conditions in Parts 8.2.1.1 thru 8.2.1.5 are met; or (2) the permittee has transferred all areas under its control to another operator, and that operator has submitted and obtained coverage under this permit; or (3) the permittee has obtained coverage under a different NPDES permit for the same discharges.

Completing the Form Type or print, using uppercase letters, in the appropriate areas only. Please place each character between the marks.

Abbreviate if necessary to stay within the number of characters allowed for each item. Use only one space for breaks between words, but not for punctuation marks unless they are needed to clarify your response. If you have any questions about this form, refer to www.epa.gov/npdes/stormwater/cgp or telephone EPA’s NOI Processing Center at (866) 352-7755. Please submit original document with signature in ink - do not send a photocopied signature.

Section I. Approval to Use Paper NOT Form You must indicate whether you have been given approval by the EPA Regional Office to use a paper NOT. Note that you are not authorized to use this paper NOT form unless the Regional Office has approved its use.

Section II. Permit Number Enter the existing NPDES Stormwater General Permit Tracking Number assigned to the project by EPA’s Stormwater Notice Processing Center. If you do not know the permit tracking number, refer to http://www.epa.gov/npdes/stormwater/cgp or contact EPA’s NOI Processing Center at (866) 352-7755.

Indicate your reason for submitting this Notice of Termination by checking the appropriate box. Check only one:

You have completed earth-disturbing activities at your site and, if applicable, construction support activities covered by this permit (see Part 1.6.3) and you have met all other requirements in Part 8.2.1.

Another operator has assumed control over all areas of the site and that operator has submitted an NOI and obtained coverage under the CGP.

You have obtained coverage under an individual permit or another general NPDES permit addressing stormwater discharges from the construction site.

Section III. Operator Information Provide the legal name of the person, firm, public organization, or any other entity that operates the project described in this application and is covered by the permit tracking number identified in Section I. Refer to Appendix A of the permit for the definition of “operator”. Provide the employer identification number (EIN from the Internal Revenue Service; IRS). If the applicant does not have an EIN enter “NA” in the space provided. Enter the complete mailing address, telephone number, and email address of the operator. Optional: enter the fax number of the operator.

Section IV. Project/Site Information Enter the official or legal name and complete street address, including city, state, zip code, and county or similar government subdivision of the project or site. If the project or site lacks a street address, indicate the general location of the site (e.g., Intersection of State Highways 61 and 34). Complete site information must be provided for termination of permit coverage to be valid.

Section V. Certification Information

All applications, including NOIs, must be signed as follows:

For a corporation: By a responsible corporate officer. For the purpose of this Part, a responsible corporate officer means: (i) a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy-or decision-making functions for the corporation, or (ii) the manager of one or more manufacturing, production, or operating facilities, provided, the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.

For a partnership or sole proprietorship: By a general partner or the proprietor, respectively; or

For a municipality, state, federal, or other public agency: By either a principal executive officer or ranking elected official. For purposes of this Part, a principal executive officer of a federal agency includes (i) the chief executive officer of the agency, or

(ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrator of EPA).

Include the name, title, and email address of the person signing the form and the date of signing. An unsigned or undated NOT form will not be considered valid termination of permit coverage.

Paperwork Reduction Act Notice

Public reporting burden for this application is estimated to average 0.5 hours per notice, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding the burden estimate, any other aspect of the collection of information, or suggestions for improving this form including any suggestions which may increase or reduce this burden to: Chief, Information Policy Branch, 2136, U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460. Include the OMB number on any correspondence. Do not send the completed form to this address.

http://www.epa.gov/npdes/stormwater/cgp http://www.epa.gov/npdes/stormwater/cgp

Instructions for Completing EPA Form 3510-13

Notice of Termination (NOT) of Coverage Under an NPDES General Permit for Stormwater Discharges Associated with Construction Activity

NPDES Form Date (2/16) This Form Replaces Form 3510-13 (12/08) Form Approved OMB No. 2040-0004

EPA Form 3510-13 Page 3 of 3

Submitting Your Form:

Submit your NOI form by mail to one of the following addresses:

For Regular U.S. Mail Delivery:

Stormwater Notice Processing Center Mail Code 4203M

U.S. EPA

1200 Pennsylvania Avenue, NW Washington, DC 20460

For Overnight/Express Mail Delivery:

Stormwater Notice Processing Center EPA East Building - Room 7420

U.S. EPA

1201 Constitution Avenue, NW Washington, DC 20004

Visit this website for instructions on how to submit electronically:

www.epa.gov/npdes/stormwater/cgpenoi http://www.epa.gov/npdes/stormwater/cgpenoi