j17 Storm Water Runoff Permit Terminaiton Request.pdf

TERMINATION REQUEST – GENERAL PERMIT NUMBER ALR100000

NPDES PERMIT NUMBER ALR100000 IS A GENERAL PERMIT AUTHORIZING DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES THAT RESULT IN A TOTAL LAND DISTURBANCE OF ONE ACRE OR GREATER AND SITES LESS THAN ONE ACRE BUT ARE PART OF A LARGER COMMON PLAN OR DEVELOPMENT OR SALE

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

PLEASE COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES WILL DELAY PROCESSING. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS NECESSARY. ATTACH CBMPP AND OTHER INFORMATION AS NEEDED. PLEASE TYPE OR

PRINT LEGIBLY IN INK.

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.

1. Yes No 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. Yes No Has the Permittee lost operational control of the facility/site?

3. Yes No Has the Permittee lost legal responsibility for the facility/site?

If “Yes” to any or all of questions 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:

“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.”

Name & Designation of QCP

Signature Date

Name & Title of Responsible Official

Signature Date

ADEM Form 21 5/14 m1 Page 1 of 1

Water Division