Form CN-1175 "Notice of Termination (Not) for General Npdes Permit for Stormwater Discharges From Construction Activities (Cgp)" - Tennessee

What Is Form CN-1175?

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

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Tennessee Department of Environment & Conservation;
  • 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 Form CN-1175 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Environment & Conservation.

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Download Form CN-1175 "Notice of Termination (Not) for General Npdes Permit for Stormwater Discharges From Construction Activities (Cgp)" - Tennessee

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TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION (TDEC)
Division of Water Resources
William R. Snodgrass Tennessee Tower, 312 Rosa L. Parks Avenue, 11th Floor, Nashville, Tennessee 37243
1-888-891-TDEC (8332)
Notice of Termination (NOT) for General NPDES Permit for Stormwater Discharges from Construction Activities (CGP)
This form is required to be submitted when requesting termination of coverage from the CGP. The purpose of this form is to notify the TDEC
that either all stormwater discharges associated with construction activity from the portion of the identified facility where you, as an operator,
have ceased or have been eliminated; or you are no longer an operator at the construction site. Submission of this form shall in no way relieve the
permittee of permit obligations required prior to submission of this form. Please submit this form to the local DWR Environmental Field Office
(EFO) address (see table below). For more information, contact your local EFO at the toll-free number 1-888-891-8332 (TDEC).
Type or print clearly, using ink.
NPDES Tracking
Site or Project Name:
Number: TNR
Street Address or Location:
County(ies):
Name of Permittee Requesting Termination of Coverage:
Permittee Contact Name:
Title or Position:
Mailing Address:
City:
State:
Zip:
Phone:
E-mail:
Check the reason(s) for termination of permit coverage:
Stormwater discharge associated with construction activity is no longer occurring and the permitted area has a uniform 70% permanent
vegetative cover OR has equivalent measures such as rip rap or geotextiles, in areas not covered with impervious surfaces.
You are no longer the operator at the construction site (i.e., termination of site-wide, primary or secondary permittee coverage).
Certification and Signature: (must be signed by president, vice-president or equivalent ranking elected official)
I certify under penalty of law that either: (a) all stormwater discharges associated with construction activity from the portion of the identified
facility where I was an operator have ceased or have been eliminated or (b) I am no longer an operator at the construction site. I understand that
by submitting this notice of termination, I am no longer authorized to discharge stormwater associated with construction activity under this
general permit, and that discharging pollutants in stormwater associated with construction 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.
For the purposes of this certification, elimination of stormwater discharges associated with construction activity means that all stormwater
discharges associated with construction activities from the identified site that are authorized by a NPDES general permit have been eliminated
from the portion of the construction site where the operator had control. Specifically, this means that all disturbed soils at the portion of the
construction site where the operator had control have been finally stabilized, the temporary erosion and sediment control measures have been
removed, and/or subsequent operators have obtained permit coverage for the site or portions of the site where the operator had control.
I certify under penalty of law that this document and all attachments were prepared by me, or under my direction or supervision. The submitted
information 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. As specified in Tennessee Code Annotated Section 39-16-702(a)(4), this
declaration is made under penalty of perjury.
Permittee name (print or type):
Signature:
Date:
EFO
Street Address
Zip Code
EFO
Street Address
Zip Code
Memphis
8383 Wolf Lake Drive, Bartlett, TN
38133
Cookeville
1221 South Willow Ave.
38506
Jackson
1625 Hollywood Drive
38305
Chattanooga
1301 Riverfront Parkway, Ste. 206
37402
Nashville
711 R S Gass Boulevard
37243
Knoxville
3711 Middlebrook Pike
37921
Columbia
1421 Hampshire Pike
38401
Johnson City
2305 Silverdale Road
37601
CN-1175 (Rev. 03-18)
RDA 2366
TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION (TDEC)
Division of Water Resources
William R. Snodgrass Tennessee Tower, 312 Rosa L. Parks Avenue, 11th Floor, Nashville, Tennessee 37243
1-888-891-TDEC (8332)
Notice of Termination (NOT) for General NPDES Permit for Stormwater Discharges from Construction Activities (CGP)
This form is required to be submitted when requesting termination of coverage from the CGP. The purpose of this form is to notify the TDEC
that either all stormwater discharges associated with construction activity from the portion of the identified facility where you, as an operator,
have ceased or have been eliminated; or you are no longer an operator at the construction site. Submission of this form shall in no way relieve the
permittee of permit obligations required prior to submission of this form. Please submit this form to the local DWR Environmental Field Office
(EFO) address (see table below). For more information, contact your local EFO at the toll-free number 1-888-891-8332 (TDEC).
Type or print clearly, using ink.
NPDES Tracking
Site or Project Name:
Number: TNR
Street Address or Location:
County(ies):
Name of Permittee Requesting Termination of Coverage:
Permittee Contact Name:
Title or Position:
Mailing Address:
City:
State:
Zip:
Phone:
E-mail:
Check the reason(s) for termination of permit coverage:
Stormwater discharge associated with construction activity is no longer occurring and the permitted area has a uniform 70% permanent
vegetative cover OR has equivalent measures such as rip rap or geotextiles, in areas not covered with impervious surfaces.
You are no longer the operator at the construction site (i.e., termination of site-wide, primary or secondary permittee coverage).
Certification and Signature: (must be signed by president, vice-president or equivalent ranking elected official)
I certify under penalty of law that either: (a) all stormwater discharges associated with construction activity from the portion of the identified
facility where I was an operator have ceased or have been eliminated or (b) I am no longer an operator at the construction site. I understand that
by submitting this notice of termination, I am no longer authorized to discharge stormwater associated with construction activity under this
general permit, and that discharging pollutants in stormwater associated with construction 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.
For the purposes of this certification, elimination of stormwater discharges associated with construction activity means that all stormwater
discharges associated with construction activities from the identified site that are authorized by a NPDES general permit have been eliminated
from the portion of the construction site where the operator had control. Specifically, this means that all disturbed soils at the portion of the
construction site where the operator had control have been finally stabilized, the temporary erosion and sediment control measures have been
removed, and/or subsequent operators have obtained permit coverage for the site or portions of the site where the operator had control.
I certify under penalty of law that this document and all attachments were prepared by me, or under my direction or supervision. The submitted
information 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. As specified in Tennessee Code Annotated Section 39-16-702(a)(4), this
declaration is made under penalty of perjury.
Permittee name (print or type):
Signature:
Date:
EFO
Street Address
Zip Code
EFO
Street Address
Zip Code
Memphis
8383 Wolf Lake Drive, Bartlett, TN
38133
Cookeville
1221 South Willow Ave.
38506
Jackson
1625 Hollywood Drive
38305
Chattanooga
1301 Riverfront Parkway, Ste. 206
37402
Nashville
711 R S Gass Boulevard
37243
Knoxville
3711 Middlebrook Pike
37921
Columbia
1421 Hampshire Pike
38401
Johnson City
2305 Silverdale Road
37601
CN-1175 (Rev. 03-18)
RDA 2366