J17_NPDES NOT.pdf

ADEM Form 021 Notice of Termination – NPDES General Permit Number ALR100000

(Construction Stormwater)

Pursuant to ADEM Admin. Code r. 335-6-1-.04 and the NPDES General Permit Number ALR100000, Notices of Termination for NPDES General Permit Number ALR100000 (ADEM Form 021) are currently required to be submitted electronically. ADEM’s Alabama Environmental Permitting and Compliance System (AEPACS) at https:\\adem.alabama.gov/AEPACS is now the only method available for electronic submission of such Notices of Termination. The form package include the electronic version of ADEM Form 021 in a human readable format.

Applicants may apply for a waiver from electronic submittal of this form in accordance with ADEM Admin. Code r. 335-6-1-.04(6), but a hardcopy submittal of ADEM Form 021 may not be accepted unless the Department first approves such waiver. The hardcopy form is also include at the end of this form package. There may be differences between the electronic versions of the forms due to the availability of conditionality and the ability to prefill data fields.

https://adem.alabama.gov/aepacs kara.malone Typewritten Text Attachment J17 NPDES NOT 2 May 2023

Construction Stormwater (ALR100000) - Voluntary Termination (Form 021) Construction Stormwater-Voluntary Termination Request

To properly terminate your permit for construction, a Notice of Termination (NOT) is required to be submitted within thirty (30) days of one of the following conditions:

(a) Final stabilization has been achieved on all portions of the facility/site. Final stabilization is defined as the application and establishment of the permanent ground cover (vegetative, pavements of erosion resistant hard or soft material or impervious structures) planned for the site to permanently eliminate soil erosion to the maximum extent practicable. Established vegetation will be considered final if 100% of the soil surface is uniformly covered in permanent vegetation with a density of 85% or greater.

Permanent vegetation shall consist of; planted trees, shrubs, perennial vines; an agricultural or a perennial crop of vegetation appropriate for the region. Final stabilization applies to each phase of construction. (ALR100000 Permit Part V.)

(b) Coverage under an individual permit or alternative general permit has been obtained.

(c) Another operator has assumed control over all areas of the site that have not achieved final stabilization and the new operator has submitted an NOI for coverage under this permit; or

Instructions

Please complete all questions and attach all necessary documentation as prompted throughout the application process. Incomplete or incorrect information will delay processing.

***No Fee Required***

CONTACT INFORMATION

Main Address

Alabama Department of Environmental Management Water Division Stormwater Management Branch Post Office Box 301463 Montgomery, Alabama 36130-1463

CONTACTS

Phone : 334-271-7836

E-mail : cswmail@adem.alabama.gov

ADDITIONAL LINKS

Please click here for area assignments and contact information for Construction Stormwater Permit staff.

mailto:cswmail@adem.alabama.gov http://adem.alabama.gov/programs/water/waterforms/ConstructionPermitsAreaAssignmentMap.pdf http://adem.alabama.gov/programs/water/waterforms/ConstructionPermitsAreaAssignmentMap.pdf

Construction Stormwater (ALR100000) - Voluntary Termination (Form 021)

Form Input

Termination Requirements

Yes No

Yes No

Yes No

Proposed Succeeding Permittee/Responsible Official

First Name Last Name

Title

Proposed Succeeding Permittee Name/Company Name

Phone Type Number Extension

Home

Mobile

Other

Business

Email

Address Line 1

Address Line 2

City State/Area Postal Code

Permit Information

Permit Number

Permittee Permittee Name

Number Extension

Home

Mobile

Other

Business

Address Line 1

Address Line 2

City State/Area Postal Code

This form may contain one or more sections or controls that are conditionally displayed based on answers provided in other parts of the form*

Has all regulated activity authorized by this Permit at this facility been completed? (i.e. construction/industrial effects removed; solid waste/debris properly disposed; all disturbed areas have been fully reclaimed, permanently stabilized, or perennial vegetative cover established; and stormwater discharges do not represent an adverse impact to water quality.)

*Select One

Has the Permittee lost operational control of the facility/site? *Select One

Has the Permittee lost legal responsibility for the facility/site? *Select One

This control is conditionally displayed based on answers provided in other parts of the form*

Phone Type *Only one phone number is accepted

Responsible Official First Name Last Name

Title

Organization Name

Phone Type Number Extension

Home

Mobile

Other

Business

Email

Address Line 1

Address Line 2

City State/Area Postal Code

Facility Information

Facility Name

Autauga Baldwin

Barbour Bibb

Blount Bullock

Butler Calhoun

Chambers Cherokee

... (More Options Available)

Facility Address Address Line 1

Address Line 2

City State/Area Postal Code

Facility Location Latitude Longitude

Qualified Credentialed Professional (QCP) Information

AL National Resources Conservation Service Professional certified by the State Conservationist Certified Professional in Erosion and Sediment Control (CPESC)

Certified Professional Soil Scientist (CPSS) Professional Engineer (PE)

Professional Geologist (PG) Registered Environmental Manager (REM)

Registered Forester Registered Land Surveyor (LS)

Registered Landscape Architect

Registration / Certification Number

Facility County *Select One

QCP Designation *Select One

Qualified Credentialed Professional Prefix

First Name Last Name

Title

Organization Name

Phone Type Number Extension

Home

Mobile

Other

Business

Email

Address Line 1

Address Line 2

City State/Area Postal Code

Duly Authorized Representative (DAR)

Pursuant to ADEM Administrative Code Rule 335-6-6-.09 (1), this NOI must be signed by a responsible official, as indicated below:

(a) In the case of a corporation, by a principal executive officer of at least the level of vice president, or a manager assigned or delegated in accordance with corporate procedures, with such delegation submitted in writing if required by the Department, who is responsible for manufacturing, production, or operating facilities and is authorized to make management decisions which govern the operation of the regulated facility;

(b) In the case of a partnership, by a general partner;

(c) In the case of a sole proprietorship, by the proprietor; or

(d) In the case of a municipal, state, federal, or other public entity by either a principal executive officer, or ranking elected official.

ADEM Administrative Code Rule 335-6-.09(2):

All reports required by permits and other information requested by the Department shall be signed by a person described in paragraph 335-6-6-.09(1) or by a duly authorized representative of that person. A person is a duly authorized representative only if:

(a) The authorization is made in writing by a person described in paragraph 335-6-6-.09(1);

(b) The authorization specifies either an individual or a position having responsibility for the overall operation of the regulated facility or activity and;

(c) The written authorization is submitted to the Department.

Yes No

DAR Documentation

Please attach appropriate documentation meeting the requirements above for a duly authorized representative. The document must be dated within the last 12 months.

Multiple attachments are not allowed. Please be aware that files exceeding 500 MB in size are not allowed. The following file types are accepted:

*.7Z,*.7z,*.AVI,*.avi,*.Avi,*.BMP,*.bmp,*.Bmp,*.CSV,*.csv,*.Csv,*.DAT,*.dat,*.Dat,*.DOC,*.doc,*.Doc,*.DOCX,*.docx,*.Docx,*.DWG,*.dwg,*.Dwg,*.EML,*.eml,*.Eml,*.GIF,*.gif,*.Gif,*.GPX,*.gpx,*.Gpx,*.HTM,*.htm,*.Htm,*.HTML,*.html,*.Html,*.HY8,*.hy8,*.Hy8,*.JPE,*.jpe,*.Jpe,*.JPEG,*.jpeg,*.Jpeg,*.JPG,*.jpg,*.Jpg,*.MOV,*.mov,*.Mov,*.MP3,*.mp3,*.Mp3,*.MP4,*.mp4,*.Mp4,*.MSG,*.msg,*.Msg,*.OGV,*.ogv,*.Ogv,*.PDF,*.pdf,*.Pdf,*.PNG,*.png,*.Png,*.PPS,*.pp2,*.Pps,*.PPT,*.ppt,*.Ppt,*.PPTX,*.pptx,*.Pptx,*.PRJ,*.prj,*.Prj,*.SDF,*.sdf,*.Sdf,*.TIF,*.tif,*.Tif,*.TIFF,*.tiff,*.Tiff,*.TXT,*.txt,*.Txt,*.WAV,*.wav,*.Wav,*.WEBM,*.webm,*.Webm,*.WMV,*.wmv,*.Wmv,*.WPD,*.wpd,*.Wpd,*.WPS,*.wps,*.Wps,*.XLS,*.xls,*.Xls,*.XLSX,*.xlsx,*.Xlsx,*.ZIP,*.zip,*.Zip,*.ZIPX,*.zipx,*.Zipx,*.F01,*.f01,*.F02,*.f02,*.F03,*.f03,*.F04,*.f04,*.F05,*.f05,*.F06,*.f06,*.F07,*.f07,*.F08,*.f08,*.F09,*.f09,*.F10,*.f10,*.F11,*.f11,*.F12,*.f12,*.F13,*.f13,*.F14,*.f14,*.F15,*.f15,*.F16,*.f16,*.F17,*.f17,*.F18,*.f18,*.F19,*.f19,*.F20,*.f20,*.G01,*.g01,*.G02,*.g02,*.G03,*.g03,*.G04,*.g04,*.G05,*.g05,*.G06,*.g06,*.G07,*.g07,*.G08,*.g08,*.G09,*.g09,*.G10,*.g10,*.G11,*.g11,*.G12,*.g12,*.G13,*.g13,*.G14,*.g14,*.G15,*.g15,*.G16,*.g16,*.G17,*.g17,*.G18,*.g18,*.G19,*.g19,*.G20,*.g20,*.O01,*.o01,*.O02,*.o02,*.O03,*.o03,*.O04,*.o04,*.O05,*.o05,*.O06,*.o06,*.O07,*.o07,*.O08,*.o08,*.O09,*.o09,*.O10,*.o10,*.O11,*.o11,*.O12,*.o12,*.O13,*.o13,*.O14,*.o14,*.O15,*.o15,*.O16,*.o16,*.O17,*.o17,*.O18,*.o18,*.O19,*.o19,*.O20,*.o20,*.P01,*.p01,*.P02,*.p02,*.P03,*.p03,*.P04,*.p04,*.P05,*.p05,*.P06,*.p06,*.P07,*.p07,*.P08,*.p08,*.P09,*.p09,*.P10,*.p10,*.P11,*.p11,*.P12,*.p12,*.P13,*.p13,*.P14,*.p14,*.P15,*.p15,*.P16,*.p16,*.P17,*.p17,*.P18,*.p18,*.P19,*.p19,*.P20,*.p20,*.R01,*.r01,*.R02,*.r02,*.R03,*.r03,*.R04,*.r04,*.R05,*.r05,*.R06,*.r06,*.R07,*.r07,*.R08,*.r08,*.R09,*.r09,*.R10,*.r10,*.R11,*.r11,*.R12,*.r12,*.R13,*.r13,*.R14,*.r14,*.R15,*.r15

Comment

Confidential (Reason for Confidentiality)

Will a duly authorized representative be submitting this Notice of Termination? *Select One

This control is conditionally displayed based on answers provided in other parts of the form*

Authorized Rep

Prefix

First Name Last Name

Title

Organization Name

Number Extension

Home

Mobile

Other

Business

Email

Mailing Address Address Line 1

Address Line 2

City State/Area Postal Code

Country

This control is conditionally displayed based on answers provided in other parts of the form*

Phone Type *Only one phone number is accepted

ADEM Form 21 06/22 m2 Page 1 of 2

ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT (ADEM)

NOTICE OF TERMINATION – NPDES GENERAL PERMIT NUMBER ALR100000

Instructions: This form may be used to submit a Notice of Termination of coverage under NPDES General Permit Number ALR100000 ONLY if the applicant has been granted a waiver from electronically submitting this form pursuant to ADEM Admin. Code r. 335-6-1-.04(6). NPDES General Permit Number ALR100000 is the general permit authorizing discharges associated with construction activities that result in a total land disturbance of one (1) acre or greater and sites less than one (1) acre but are part of a larger common plan of development or sale. Please complete all questions.

Incomplete or incorrect answers, or missing signatures will delay processing.

Mail to: Alabama Department of Environmental Management Water Division Stormwater Management Branch Post Office Box 301463 Montgomery, Alabama 36130-1463

Item I.

Permittee Name Facility/Site Name

NPDES Permit Number

ALR10

Facility Street Address or Location Description

County(s) City, State, and Zip Code

Item II.

Termination Requirements (answer each question with a Yes or No) Yes No

1. Has all regulated activity authorized by this Permit at this facility been completed? (i.e. construction/industrial effects removed; solid waste/debris properly disposed; all disturbed areas have been fully reclaimed, permanently stabilized, or perennial vegetative cover established; and stormwater discharges do not represent an adverse impact to water quality.)

2. Has the Permittee lost operational control of the facility/site?

3. Has the Permittee lost legal responsibility for the facility/site?

If the answer to one or both of Question 2 or 3, in order for this termination request to be granted, the Name, Phone Number, and Address of the succeeding responsible permittee/operator(s) must be listed and the succeeding responsible operator must obtain coverage:

Certification “I understand that discharging pollutants in storm water associated with regulated activity to waters of the State that is not authorized by NPDES permit coverage is a violation of State law. I also understand that the submittal of this request for termination does not release the operator from liability for any violations of this permit, ADEM Administrative Code Chapter 335-6-6, or other ADEM rules until a complete and correct request for termination of the permit is received by the Department. I understand that the permittee, operator, owner, developer, contractors, home builder(s), property owners association, etc., separately or collectively, must retain permit coverage for subdivision developments or other phased developments until all disturbance activity, including individual home construction, is substantially complete. I understand that should an inspection or complaint reveal significant noncompliance with ADEM rules, an environmental problem related to the discharge of stormwater from the site or that incorrect information has inadvertently been provided, implementation of remedial measures may be required, to include resubmittal of the NOI in order to correct any deficiencies, comply with federal stormwater permitting requirements, and provide for the protection of water quality. 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 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 certify that this form has not been altered, and if copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.”

Qualified Credentialed Professional (QCP) Signature

QCP Designation/Description:

Name: Title: Registration/Certification #

Address:

Phone Number: Email:

Signature Date Signed:

ADEM Form 21 06/22 m2 Page 2 of 2

Duly Authorized Representative (DAR) Signature (if applicable)

If a Duly Authorized Representative will be signing this NOT, the DAR must provide the following information and attach the appropriate documentation meeting the requirements below for a duly authorized representative. The document must be dated within the last 12 months

Name (including prefix): Title:

Organization Name:

Mailing Address:

Phone Number: Email:

Signature Date Signed:

Operator/Responsible Official Signature

Name (including prefix): Title:

Organization Name:

Mailing Address:

Phone Number: Email:

Signature Date Signed:

Pursuant to ADEM Administrative Code Rule 335-6-6-.09 (1), this NOI must be signed by a responsible official, as indicated below:

(a) In the case of a corporation, by a principal executive officer of at least the level of vice president, or a manager assigned or delegated in accordance with corporate procedures, with such delegation submitted in writing if required by the Department, who is responsible for manufacturing, production, or operating facilities and is authorized to make management decisions which govern the operation of the regulated facility;

(b) In the case of a partnership, by a general partner;

(c) In the case of a sole proprietorship, by the proprietor; or

(d) In the case of a municipal, state, federal, or other public entity by either a principal executive officer, or ranking elected official.

ADEM Administrative Code Rule 335-6-.09(2):

All reports required by permits and other information requested by the Department shall be signed by a person described in paragraph 335-6-6-.09(1) or by a duly authorized representative of that person. A person is a duly authorized representative only if:

(a) The authorization is made in writing by a person described in paragraph 335-6-6-.09(1);

(b) The authorization specifies either an individual or a position having responsibility for the overall operation of the regulated facility or activity and;

(c) The written authorization is submitted to the Department.