01560F_NPDES_NOT_Stormwater_Permittee_-_Contractor_to_Fill_Out.doc

For Official Use Only

NOTICE OF TERMINATION

VERSION 2008

(EPD District Mailing Address Revision – March 2011)

State of Georgia

Department of Natural Resources

Environmental Protection Division

To Cease Coverage Under the NPDES General Permits

To Discharge Storm Water Associated With Construction Activity

I.

PERMIT TYPE (Check Only One):

( GAR100001 - Stand Alone

( GAR100002 – Infrastructure

( GAR100003 - Common Development

II.

SITE / PERMITTEE INFORMATION

Project Construction Site Name:

GPS Location of Construction Exit (degrees/minutes/seconds):

Latitude _______º _______′ _______″ Longitude _______º _______′ _______″

Construction Site Location (information must be sufficient to accurately locate the construction site):

Subdivision Name (if applicable):

Lot Number(s) (if applicable): ___ ____ Common Development Name (applicable only to General NPDES Permit No. GAR100003):

Construction Site Street Address: ______________________________________________________

City (applicable if the site is located within the jurisdictional boundaries of the city):

County:

Owner’s Name:

____________ Phone:

Address:

City:

State:

Zip Code:

Duly Authorized Representative (optional):

Phone:

Operator’s Name (optional):

______ Phone:

Facility/Construction Site Contact:

Phone:

TYPE OF PERMITTEE (Check Only One and Complete):

( Primary Permittee

Primary Permittee's Name:

_________ Phone:

Attached to this Notice of Termination - Listing of the legal name, complete address and telephone number for each secondary permittee at the site for which this NOT is submitted

(applicable only to General NPDES Permit No. GAR100003).

Attached to this Notice of Termination - Listing of the legal name, complete address and telephone number for the legal title holders for each remaining undeveloped lot(s) at the site for which this NOT is submitted (applicable only to General NPDES Permit No. GAR100003).

( Secondary Permittee (applicable only to General NPDES Permit No. GAR100003) Primary Permittee's Name:

________ Phone:

( Tertiary Permittee (applicable only to General NPDES Permit No. GAR100003) Primary Permittee's Name (optional):

_________ Phone:

III.

SITE ACTIVITY INFORMATION

Start Date (month/date/year):

____ /____ / ____ Completion Date (month/date/year): ____ / ____ / ____

Disturbed Acreage: __________________________________________________________________

Check Only One:

( Construction Activity Ceased and Final Stabilization Completed

( No Longer Owner and/or Operator of Facility/Construction Site

Construction Activity Type:

( Commercial

( Industrial

( Municipal

( Linear

( Utility

( Residential

( Name of Initial Receiving Water(s):

( Name of MS4 Owner/Operator (if applicable):

Name of Receiving Water(s):

IV.

CERTIFICATIONS (Owner or Operator or Both to Initial as Applicable)

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 General NPDES Permit No. GAR100003, I will notify by written correspondence with return receipt certified mail (or similar service) to the subsequent legal title holder of each remaining lot(s) that these lot Owners or Operators will become tertiary permittees for purposes of General NPDES Permit No. GAR100003. 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.

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 certified 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 fines and imprisonment for knowing violations.

Owner's Printed Name:

Title:

Signature:

Date:

Operator's Printed Name:

Title:

Signature:

Date:

INSTRUCTIONS

NOTICE OF TERMINATION

NPDES General Permits for Storm Water Discharges

Associated With Construction Activity

Please print or type the Notice of Termination (NOT) form. Any NOT that contains illegible or incomplete information will not be accepted and will be returned. All information requested on the NOT must be submitted in order for the NOT to be a valid. Any information requested on the NOT that is not applicable to the owner and/or operator or the construction site must be marked “N/A.” Please do not leave any sections blank in the NOT.

Who must file a Notice of Termination (NOT) Form - When the facility/construction site has undergone final stabilization and all storm water discharges from construction activities that are authorized by the NPDES General Permits have ceased or when the Owner and/or Operator of the site changes, the permittee of the facility/construction site must submit a Notice of Termination.

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 and areas located outside the waste disposal limits of a landfill cell that has been certified by EPD for waste disposal, 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, as applicable, must be submitted to the appropriate EPD District Office as listed on the following pages. Please submit only the first three pages of this document with the applicable attachments.

Section I - Permit Type

Indicate the NPDES General Permit number (i.e., No. GAR100001, No. GAR100002, or No. GAR100003) for which this form is being submitted.

Section II - Site / Permittee Information

The construction site name and location information (i.e., GPS location of construction exit, street address, city, county) must be sufficient to accurately locate the construction site. If the construction site does not have a street address, please provide sufficient information to accurately locate the construction site. If additional space is needed, attach the location information to the NOT.

A duly authorized representative may be either a named individual or any individual occupying a named position that the permittee has authorized to sign all reports, certification statements, or other information requested by EPD.

The facility/construction site contact is the person who the permittee has assigned the responsibility for the daily on-site operational control.

Please do not leave any blanks in this section. Any information requested on the NOT that is not applicable to the permittee or to the construction site must be marked “N/A.”

Section III - Site Activity Information

Indicate by marking the appropriate box why this NOT has been submitted: (1) the facility/construction site has undergone final stabilization and all storm water discharges from construction activities that are authorized by the NPDES General Permits have ceased or (2) the Owner and/or Operator of the site have changed.

Mark the appropriate boxes to indicate the types of construction activities that were conducted at the facility/construction site.

Please do not leave any blanks in this section. Any information requested on the NOT that is not applicable to the permittee or to the construction site must be marked “N/A.”

Section IV - Certifications

The owner and/or operator must sign the Notice of Termination and initial the certification statements on the lines provided. Federal and State statutes provide specific requirements as to who is authorized to sign the Notice of Termination forms. A Notice of Termination form signed by an unauthorized person will not be valid. Please be aware that Federal and State statutes provide for severe penalties for submitting false information on this Notice of Termination form. Federal and State regulations require that the Notice of Termination form 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; and

▪ For a municipality, State, Federal or other public facility, by either a principal executive officer or ranking elected official.

GEORGIA EPD DISTRICT OFFICES

All required correspondence, including but not limited to Notices of Intent, Notices of Termination, Erosion, Sedimentation and Pollution Control Plans, certifications and any other reports shall be sent to the following EPD District Offices:

A. For facilities/construction 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

Information shall be submitted to:

West Central District Office

Georgia Environmental Protection Division

2640 Shurling Drive

Macon, GA 31211-3576

(478) 751-6612

B. For facilities/construction sites located in the following counties:

Burke, Columbia, Emanuel, Glascock, Jefferson, Jenkins, Johnson, Laurens, McDuffie, Montgomery, Richmond, Screven, Treutlen, Warren, Washington, Wheeler, Wilkinson

Information shall be submitted to:

East Central District Office

Georgia Environmental Protection Division

1885-A Tobacco Road

Augusta, GA 30906-8825

(706) 792-7744

C. For facilities/construction 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

Information shall be submitted to:

Northeast District Office

Georgia Environmental Protection Division

745 Gaines School Road

Athens, GA 30605-3129

(706) 369-6376

D. For facilities/construction sites located in the following counties:

Carroll, Clayton, Coweta, DeKalb, Douglas, Fayette, Fulton, Gwinnett, Heard, Henry, Rockdale, Spalding

Information shall be submitted to:

Mountain District - Atlanta Satellite

Georgia Environmental Protection Division

4244 International Parkway, Suite 114

Atlanta, GA 30354-3906

(404) 362-2671

E. For facilities/construction sites located in the following counties:

Bartow, Catoosa, Chattooga, Cherokee, Cobb, Dade, Dawson, Fannin, Floyd, Forsyth, Gilmer, Gordon, Habersham, Haralson, Lumpkin, Murray, Paulding, Pickens, Polk, Rabun, Towns, Union, Walker, White, Whitfield

Information shall be submitted to:

Mountain District - Cartersville Office

Georgia Environmental Protection Division

P.O. Box 3250

Cartersville, GA 30120-1705

(770) 387-4900

F. For facilities/construction 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

Information shall be submitted to:

Coastal District - Brunswick Office (Revised March 2011) Georgia Environmental Protection Division

400 Commerce Center Drive

Brunswick, GA 31523-8251

(912) 264-7284

G. For facilities/construction 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

Information shall be submitted to:

Southwest District Office

Georgia Environmental Protection Division

2024 Newton Road

Albany, GA 31701-3576

(229) 430-4144