NOTICE OF TERMINATION – 2012

Change of Owner/Operator Facility Closed Other:

A. FACILITY LOCATION INFORMATION

FACILITY NAME: PHONE: ______

STREET/LOCATION ADDRESS: ______

CITY: COUNTY: ___ _ ZIP CODE: ______

LATITUDE: LONGITUDE: (Decimal degrees = XX.XXXXXX & -XX.XXXXXX)

MAILING ADDRESS: ____ CITY: STATE: ______ZIP CODE: ______

B.FACILITY OWNER-OPERATOR INFORMATION

LEGAL NAME: PHONE: ______

MAILING ADDRESS: ______

CITY: ____ STATE: ____ ZIP CODE: ______

On-site Facility Contact:Name: _ __ _ Telephone Number:______

Title: ______Email: ______

C. COMMENTS

D. CERTIFICATION: I certify under penalty of law that all storm water discharges associated with industrial activity from the identified facility that are authorized by the 2012 IGP have been eliminated, the identified facility has closed, or the owner-operator of the identified facility has changed. I understand that by submitting this Notice of Termination, that I am no longer authorized to discharge storm water associated with industrial activity under the 2012 IGP, and that discharging pollutants in storm water associated with industrial activity to waters of the State of Georgia is unlawful under the Georgia Water Quality Control Act and the Clean Water Act where the discharge is not authorized by an NPDES permit. 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 upon 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.

Printed Name: Title: ______

Signature: ______Date: ______

Type All Information

Instructions

Notice of Termination (NOT) For Storm Water Discharges

Associated with Industrial Activity

NPDES General Permit GAR050000 (2012 IGP)

Who must file a Notice of Termination (NOT) Form

This Notice of Termination must be typed. Any NOT that contains illegible information will not be accepted. All information on this NOT must be submitted to be a valid notice. Information requested on the NOT that is not applicable to the owner-operator or the facility must be marked “N/A”. Do not leave any blanks.

In situations where all storm water discharges associated with industrial activity that are authorized by the General NPDES Permit No. GAR050000 have been eliminated or the regulated industrial activity conducted by the permittee at the identified facility has ceased (facility closure, change of operator, etc), the permittee must submit this NOT. By submitting this NOT, the permittee (operator/owner) certifies that all storm water discharges have ceased, the facility is no longer required to have coverage under the 2012 IGP for the storm water discharges, the facility is no longer operated by the permittee, or similar circumstances exist at the facility.

It is very important to read the 2012 IGP carefully before submitting this NOT. If you have questions regarding NPDES Storm Water Permitting, contact the Storm Water Unit of the NonPoint Source Program at (404) 675-6240. The completed NOT should be submitted to the following address via return receipt/certified mail or similar service:

Georgia Environmental Protection Division

NonPoint Source Program

2 Martin Luther King, Jr. Drive, S.W., Suite 1462

Atlanta, Georgia 30334

The Environmental Protection Division (EPD) does not acknowledge receipt of an NOT; therefore, the return receipt serves as confirmation of submittal. Retain a copy of the return receipt with a copy of the original NOT for your records.

This form and a copy of the 2012 IGP are available at:

Section A. Facility Information: Enter the facility’s name, street address, mailing address, county, and telephone number. Should the facility lack a street address, describe where the facility is located in “Section C. Comments.” Indicate the reason why this NOT is being submitted. Should “other” be marked, indicate why in the “Section C. Comments”. Provide the latitude and longitude of the approximate center of the facility to the nearest 15 seconds. This information can be obtained by consulting a United States Geological Service topographical map. Enter the name, title, and the telephone number of the individual who will serve as the facility contact.

Section B. Facility Owner-Operator Information: Enter the owner-operator’s legal name, mailing address and telephone number.

Section C. Comments: Provide comments as appropriate.

Section D. Certification: Provide the information requested and sign the NOT in accordance with B.7 of the 2012 IGP. Federal and State regulations require this NOT to be signed by one of the following people:

For a corporation: by a responsible corporate officer;

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.

Signature of the NOT by parties other than the above does not constitute a valid NOT submittal.

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