ADEM Form 30 "Notice of Termination - General Permit Number Alg870000" - Alabama

What Is ADEM Form 30?

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 November 1, 2012;
  • 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 30 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 30 "Notice of Termination - General Permit Number Alg870000" - Alabama

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NOTICE OF TERMINATION – GENERAL PERMIT NUMBER ALG870000
NPDES PERMIT NUMBER ALG870000 IS A GENERAL PERMIT AUTHORIZING DISCHARGES FROM THE APPLICATION
OF PESTICIDES
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 OTHER INFORMATION AS NEEDED. PLEASE TYPE OR PRINT LEGIBLY IN INK.
I. NPDES PERMIT NUMBER
ALG87
II. OPERATOR INFORMATION
Operator Name
Operator Mailing Address
Operator Phone Number
City, State, Zip
Operator E-mail Address
Contact Name and Title
Contact Phone Number
III. BASIS FOR TERMINATION
Please check only one:
A new operator has taken over responsibility for the pest treatment. For this termination request to be granted, the Name, Phone Number,
Address and Contact of the succeeding operator must be listed, and the succeeding operator must obtain new or modify existing permit coverage:
Discharges from the application of pesticides for which permit coverage was obtained have ceased, or there is not or will no longer be a pesticide
discharge.
Permit coverage has been obtained under an individual or alternative general permit for all pesticide discharges requiring NPDES permit
.
coverage. Please provide the individual or alternative general permit number:
IV. CERTIFICATION OF OPERATOR RESPONSIBLE OFFICIAL
I certify under penalty of law that I have met at least one of the reasons for terminating permit coverage listed in Section III above. I understand that
by submitting this Notice of Termination, I am no longer authorized to discharge pesticides to waters of the State. This document and all attachments
were prepared under my direction and supervision in accordance with a system designed to ensure that qualified personnel properly gather and
evaluate the information submitted. 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 or imprisonment. Additionally, I understand that
the submittal of the Notice of Termination does not release a pesticide operator from liability for any violations of ADEM Admin. Code ch. 335-6-6
and the Alabama Water Pollution Control Act.
Name (type or print)
Official Title
Signature
Date Signed
ADEM Form 30 11/12
Page 1 of 1
Print Form
NOTICE OF TERMINATION – GENERAL PERMIT NUMBER ALG870000
NPDES PERMIT NUMBER ALG870000 IS A GENERAL PERMIT AUTHORIZING DISCHARGES FROM THE APPLICATION
OF PESTICIDES
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 OTHER INFORMATION AS NEEDED. PLEASE TYPE OR PRINT LEGIBLY IN INK.
I. NPDES PERMIT NUMBER
ALG87
II. OPERATOR INFORMATION
Operator Name
Operator Mailing Address
Operator Phone Number
City, State, Zip
Operator E-mail Address
Contact Name and Title
Contact Phone Number
III. BASIS FOR TERMINATION
Please check only one:
A new operator has taken over responsibility for the pest treatment. For this termination request to be granted, the Name, Phone Number,
Address and Contact of the succeeding operator must be listed, and the succeeding operator must obtain new or modify existing permit coverage:
Discharges from the application of pesticides for which permit coverage was obtained have ceased, or there is not or will no longer be a pesticide
discharge.
Permit coverage has been obtained under an individual or alternative general permit for all pesticide discharges requiring NPDES permit
.
coverage. Please provide the individual or alternative general permit number:
IV. CERTIFICATION OF OPERATOR RESPONSIBLE OFFICIAL
I certify under penalty of law that I have met at least one of the reasons for terminating permit coverage listed in Section III above. I understand that
by submitting this Notice of Termination, I am no longer authorized to discharge pesticides to waters of the State. This document and all attachments
were prepared under my direction and supervision in accordance with a system designed to ensure that qualified personnel properly gather and
evaluate the information submitted. 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 or imprisonment. Additionally, I understand that
the submittal of the Notice of Termination does not release a pesticide operator from liability for any violations of ADEM Admin. Code ch. 335-6-6
and the Alabama Water Pollution Control Act.
Name (type or print)
Official Title
Signature
Date Signed
ADEM Form 30 11/12
Page 1 of 1