"Notice of Termination for Npdes Permit No.1200-z and 1200-a" - Oregon

Notice of Termination for Npdes Permit No.1200-z and 1200-a is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

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  • Released on September 5, 2018;
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Notice of Termination
Department of Environmental Quality
Industrial Stormwater Program
for NPDES Permit No. 1200-Z and 1200-A
National Pollutant Discharge Elimination System
Industrial Stormwater Discharge General Permits
Until termination has been approved in writing by DEQ, you must comply with all permit conditions
A. Reference Information
1. Legal Name:
2. Common Name:
3. Legal Contact:
4. Facility Contact:
Address:
Facility Physical Address:
City, State, Zip Code:
City, State, Zip Code:
Telephone # :
County:
Email:
Telephone # :
Email:
5. Permit # :
6. Facility/File ID #:
B. Termination of Permit Coverage Information
Reason for Termination
Provide an explanation below or attach a written statement explaining the reason for termination of permit
coverage and complete the requested information below. (Examples include relocation of the facility, facility’s
new industrial activity and new primary standard industry code, industrial activity and materials have been
removed):
To terminate 1200-Z permit coverage, you must meet one or more of the following conditions in accordance with
Schedule D.5 of the permit. To terminate 1200-A permit coverage, you must complete at least one of Conditions 1
through 3 below.
Provide all the requested information associated with each of the conditions appropriate for your facility.
Yes
No
Condition 1:
a) All industrial operations and stormwater discharge associated with industrial activity have ceased as defined
in
40 CFR
122.26(b)(14).
b) Attach photos of all areas of your facility that have been previously exposed to industrial activities,
including loading and unloading areas, storage of significant materials and wastes.
Page 1 of 3
1200-Z/A NOT; MRB,9/5/2018
Notice of Termination
Department of Environmental Quality
Industrial Stormwater Program
for NPDES Permit No. 1200-Z and 1200-A
National Pollutant Discharge Elimination System
Industrial Stormwater Discharge General Permits
Until termination has been approved in writing by DEQ, you must comply with all permit conditions
A. Reference Information
1. Legal Name:
2. Common Name:
3. Legal Contact:
4. Facility Contact:
Address:
Facility Physical Address:
City, State, Zip Code:
City, State, Zip Code:
Telephone # :
County:
Email:
Telephone # :
Email:
5. Permit # :
6. Facility/File ID #:
B. Termination of Permit Coverage Information
Reason for Termination
Provide an explanation below or attach a written statement explaining the reason for termination of permit
coverage and complete the requested information below. (Examples include relocation of the facility, facility’s
new industrial activity and new primary standard industry code, industrial activity and materials have been
removed):
To terminate 1200-Z permit coverage, you must meet one or more of the following conditions in accordance with
Schedule D.5 of the permit. To terminate 1200-A permit coverage, you must complete at least one of Conditions 1
through 3 below.
Provide all the requested information associated with each of the conditions appropriate for your facility.
Yes
No
Condition 1:
a) All industrial operations and stormwater discharge associated with industrial activity have ceased as defined
in
40 CFR
122.26(b)(14).
b) Attach photos of all areas of your facility that have been previously exposed to industrial activities,
including loading and unloading areas, storage of significant materials and wastes.
Page 1 of 3
1200-Z/A NOT; MRB,9/5/2018
Notice of Termination Form
Condition 2:
Yes
No
Coverage under an individual NPDES permit has been obtained
Provide the individual NPDES permit number and regulatory agency (if other than Oregon DEQ):
New NPDES Permit #
Regulatory Agency (if other than Oregon DEQ):
Yes
No
Condition 3:
A new owner or operator legally acquired responsibility of property or industrial activity
Provide the name and contact information of the new owner or operator:
Condition 4:
Yes
No
Conditions for termination under sector G (metal mining) and H (coal mining) have been met?
C. Certification
Please read the certification statement carefully before signing.
I certify under penalty of law that all stormwater discharges associated with industrial activity from the identified facility that are
authorized by a NPDES General Permit have been eliminated or that I am no longer the operator of the facility. I understand that
by submitting this Notice of Termination, I am no longer authorized to discharge stormwater associated with industrial activity
under this general permit, and that discharging pollutants in stormwater associated with industrial activity 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 the
submittal of this Notice of Termination does not release an operator from liability for any violations of this permit or the Clean
Water Act.
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 am aware that there are significant
penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
_____________________________________________
_____________________________________________
Name of Legally Authorized Representative
Title
_____________________________________________
Signature of Legally Authorized Representative
Date
Page 2 of 3
1200-Z/A NOT; MRB,9/5/2018
Notice of Termination Form
Notice of Termination Instructions
Who May File a Notice of Termination (NOT) Form?
Permit registrants who are presently covered under an Oregon Department of Environmental Quality NPDES Industrial Stormwater
Discharge General Permit Nos. 1200-Z or 1200-A may submit this form when their facilities no longer have any stormwater discharges
associated with industrial activity as defined in the stormwater regulations at 40 CFR 122.26(b)(l4), or when they are no longer the
operator of the facility, or coverage under and individual NPDES permit has been obtained.
A. Facility Information
1.
Give the legal name of the person, firm, public organization, or any other entity that operates the facility or site described in this
application.
2.
The name of the facility contact may or may not be the same name as the legal contact.
3/4. Enter the complete address and telephone number of the legal and facility contact.
5.
Enter the existing NPDES Stormwater General Permit number (e.g. 1200-Z or 1200-A)
6.
Enter the DEQ File number provided to the facility when you registered for coverage under the permit. The DEQ file number can be
found on the first page of your permit. If you do not know the permit or file number, contact DEQ regional office or DEQ Agents.
B. Reason for submitting Notice of Termination
Please complete one or more of the conditions described in this section and provide a brief narrative description of the reason of
termination. Reasons for termination include:
• You are no longer the operator of the facility or site.
• There are no industrial activities at the site that require permit coverage.
• All stormwater discharges associated with industrial activities at the facility or site have ceased.
• Coverage under an individual NPDES permit has been obtained.
C. Certification
Federal statutes provide for severe penalties for submitting false information on this application form. Federal regulations require this
application to be signed as follows:
• For a corporation: by a responsible corporate officer, which means (I) president, secretary, treasurer, or vice president of the
corporation in charge of a principal business function, or any other person who performs similar policy or decision making
functions, or (II) the manager of one or more manufacturing, production or operating facilities employing more than 250
persons or having gross annual sales or expenditures exceeding $25 million (in second-quarter 1980 dollars) if authority to sign
documents has been assigned or delegated to the manager in accordance with corporate procedures; or
• For a partnership or sole proprietorship: by a general partner or the proprietor; or
• For a municipality, State, Federal, or other public facility: by either a principal executive officer or ranking elected official.
Application Submittal
Please send the completed form and supporting materials to the DEQ regional office or Agent office.
DEQ Northwest Region
DEQ Western Region
DEQ Eastern Region
700 Lloyd Building
165 East 7th Avenue, Suite 100
800 SE Emigrant Avenue, Suite 330
700 NE Multnomah St., Suite #600,
Eugene, OR 97401
Pendleton, OR 97801
Portland, OR 97232
541-686-7930
541-278-4605
503-229-5263
Benton, Coos, Curry, Douglas, Jackson,
Baker, Crook, Deschutes, Gilliam,
Josephine, Lane, Lincoln, Linn, Marion, Polk,
Grant, Harney, Hood River, Jefferson,
Clackamas, Clatsop, Columbia, Multnomah,
Klamath, Lake, Malheur, Marrow,
Yamhill
Tillamook, Washington
Sherman, Umatilla, Union, Wallowa,
Wasco, Wheeler
1200-Z AGENT
1200-Z and 1200-A AGENT
1200-Z AGENT
1200-A AGENT
Clean Water Services
City of Eugene
City of Portland
Department of Geology
2550 SW Hillsboro Highway
Bureau of Environmental
Industrial Stormwater
and Mineral Industries
Hillsboro, OR 97123
Services
229 Broadalbin St SW,
410 River Ave.
503-681-5175
Water Pollution Control
Albany, OR 97321
Eugene, OR 97404
Laboratory
(541) 967-2082
Includes Banks, Beaverton,
541-682-8616
6543 N. Burlington Ave.
Cornelius, Durham, Forest Grove,
Gaston, Hillsboro, King City, North
Portland, OR 97203-5452
Plains, Sherwood, Tigard, Tualatin,
503-823-5547
and portions of Washington Co.
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1200-Z/A NOT; MRB,9/5/2018
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