"Notice of Termination for Npdes General Permit to Discharge Stormwater Associated With Construction Activity" - Oregon

Notice of Termination for Npdes General Permit to Discharge Stormwater Associated With Construction Activity is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • Released on June 28, 2018;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
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Notice of Termination
For NPDES General Permit to Discharge Stormwater
Associated With Construction Activity
Use this form to end permit coverage once all soil disturbance activities have been completed and final
stabilization of exposed soils has occurred. Please print in ink or type.
Submit photos that depict site stabilization, unless the site has been inspected by DEQ or Agent.
PERMIT REGISTRANT
Name (authorized person meeting the signature requirements on the application):
Telephone:
Company (Legal Name - Permit Registrant):
Mailing Address:
City, State, Zip Code:
E-mail Address:
File Number (located on face page of permit):
SITE LOCATION/ADDRESS
STATUS OF CONSTRUCTION ACTIVITY
Site Common Name:
All soil disturbance activities by or for the registrant have
been completed.
Street Address (or Location Description):
The site has undergone stabilization of all exposed soils
through vegetation, paving, or building construction (for a
common plan of development or sale, all remaining
disturbed areas are covered by either a small lot permit or
the 1200-CN).
All stormwater discharges from construction activities that
are authorized by this permit are eliminated.
All temporary erosion and sediment controls have been
City (or nearest city):
removed and properly disposed, unless local ordinance
requires otherwise in the completion of the project.
County:
_______________
Date above items were completed:
OR
Project was cancelled with no disturbance taking place.
CERTIFICATION
Please read the certification statement carefully before signing.
I certify under penalty of law that all stormwater discharges associated with construction activity from this site that are
authorized by this NPDES general permit have been eliminated. By submitting this Notice of Termination, I understand
that I am no longer authorized to discharge stormwater associated with construction activity under this general permit, and
that discharging pollutants to waters of the United States is unlawful under the Clean Water Act where the discharge is not
authorized by a NPDES permit. I also understand that submittal of this Notice of Termination does not release a permittee
from liability for any violations of this permit or the Clean Water Act.
________________________________________________________ ______________________________________
Signature of Legally Authorized Representative
Date
_________________________________________________________
Name of Legally Authorized Representative (type or print)
Updated by: Mark Riedel-Bash
Rev: 06.28.2018
Notice of Termination
For NPDES General Permit to Discharge Stormwater
Associated With Construction Activity
Use this form to end permit coverage once all soil disturbance activities have been completed and final
stabilization of exposed soils has occurred. Please print in ink or type.
Submit photos that depict site stabilization, unless the site has been inspected by DEQ or Agent.
PERMIT REGISTRANT
Name (authorized person meeting the signature requirements on the application):
Telephone:
Company (Legal Name - Permit Registrant):
Mailing Address:
City, State, Zip Code:
E-mail Address:
File Number (located on face page of permit):
SITE LOCATION/ADDRESS
STATUS OF CONSTRUCTION ACTIVITY
Site Common Name:
All soil disturbance activities by or for the registrant have
been completed.
Street Address (or Location Description):
The site has undergone stabilization of all exposed soils
through vegetation, paving, or building construction (for a
common plan of development or sale, all remaining
disturbed areas are covered by either a small lot permit or
the 1200-CN).
All stormwater discharges from construction activities that
are authorized by this permit are eliminated.
All temporary erosion and sediment controls have been
City (or nearest city):
removed and properly disposed, unless local ordinance
requires otherwise in the completion of the project.
County:
_______________
Date above items were completed:
OR
Project was cancelled with no disturbance taking place.
CERTIFICATION
Please read the certification statement carefully before signing.
I certify under penalty of law that all stormwater discharges associated with construction activity from this site that are
authorized by this NPDES general permit have been eliminated. By submitting this Notice of Termination, I understand
that I am no longer authorized to discharge stormwater associated with construction activity under this general permit, and
that discharging pollutants to waters of the United States is unlawful under the Clean Water Act where the discharge is not
authorized by a NPDES permit. I also understand that submittal of this Notice of Termination does not release a permittee
from liability for any violations of this permit or the Clean Water Act.
________________________________________________________ ______________________________________
Signature of Legally Authorized Representative
Date
_________________________________________________________
Name of Legally Authorized Representative (type or print)
Updated by: Mark Riedel-Bash
Rev: 06.28.2018
INSTRUCTIONS FOR COMPLETING THE NOTICE OF TERMINATION FORM FOR THE NPDES
GENERAL PERMIT TO DISCHARGE STORMWATER ASSOCIATED WITH CONSTRUCTION
This Notice of Termination Form is for a registrant that currently is assigned coverage under Oregon’s NPDES general
permit for the discharge of stormwater associated with construction activity. Use this form to end permit coverage once all
soil disturbance activities have been completed by and for the registrant and stabilization of exposed soils has occurred.
Please print in ink or type.
I.
Permit Registrant
Complete as indicated. The permit registrant is the name of the company or person as it appears on the permit.
Only the registrant or the registrant's legally authorized representative has authority to terminate permit coverage.
Note: If you are not the current registrant but should be, you need to transfer the permit. Please use the Transfer
of Ownership form at
http://www.deq.state.or.us/wq/stormwater/constappl.htm
or contact DEQ at one of the
offices listed below.
II.
Site Address/Location
Complete as indicated. Also provide the city (or nearest city) and county for the construction site.
III.
Construction Activity
Check the "boxes" to indicate that all stormwater discharges associated with construction activity have been
eliminated, stabilization of the site is complete, and temporary erosion and sediment control measures have been
properly disposed unless local codes require that they remain. Also, provide the date of completion for these
activities. As an alternative to the preceding, if the site work was never started you can check the last box only.
Your permit will not be terminated if these activities have not been completed or the construction activities started
but the project was cancelled without completing the activities.
Photo-Documentation
Submit photo-documentation that depicts site stabilization, unless the site has been inspected by DEQ or Agent.
Certification
This statement should be read carefully by the registrant, owner or legally authorized representative. The person
signing this form must print or type their name for clarity then sign and date the document on the lines provided.
Definition of Legally Authorized Representative:
See 40 CFR 122.22 for more detail. Also, please also provide the information requested in brackets [ ]
♦ Corporation - President, secretary, treasurer, vice-president, or any person who performs principal business functions; or a
manager of one or more facilities employing more than 250 persons or having gross annual sales or expenditures exceeding
$25 million that is authorized in accordance to corporate procedure to sign such documents
♦ Partnership - General partner [list of general partners, their addresses and telephone numbers]
♦ Sole Proprietorship - Owner(s) [each owner must sign the application]
♦ City, County, State, Federal, or other Public Facility - Principal executive officer or ranking elected official
♦ Limited Liability Company - Member [articles of organization]
Trusts - Acting trustee [list of trustees, their addresses and telephone numbers]
Form Submittal
Submit this form along with photo-documentation that depicts site stabilization to the appropriate
and For More
regional office. There is no fee required for this action. If you have any questions, please contact
Information
the appropriate regional offices listed below.
DEQ Northwest Region
DEQ Western Region
DEQ Eastern Region
700 NE Multnomah St., Suite 600,
165 East 7th Avenue, Suite 100
800 SE Emigrant Ave, Suite 330
Portland, OR 97232
Eugene, OR 97401
Pendleton, OR 97801
503-229-5438
541-686-7930
541-278-4605
Clackamas
Benton
Lane
Baker
Hood River
Sherman
Clatsop
Coos
Lincoln
Crook
Jefferson
Umatilla
Columbia
Curry
Linn
Deschutes
Klamath
Union
Multnomah
Douglas
Marion
Gilliam
Lake
Wallowa
Tillamook
Jackson
Polk
Grant
Malheur
Wasco
Washington
Josephine
Yamhill
Harney
Marrow
Wheeler
Updated by: Mark Riedel-Bash
Rev: 06.28.2018
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