ADEM Form 21 "Termination Request - General Permit Number Alr100000" - Alabama

What Is ADEM Form 21?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2014;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ADEM Form 21 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 21 "Termination Request - General Permit Number Alr100000" - Alabama

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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
Facility Street Address or Location Description
ALR10
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
Submit by Email
Print Form
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
Facility Street Address or Location Description
ALR10
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