Complete and Submit to Request Termination of Coverage Under Requirements Of

ATTACHMENT C – NOTICE OF TERMINATION

Complete and Submit to Request Termination of Coverage Under Requirements of

General Waste Discharge Requirements for Discharge or Reuse of Extracted and Treated Groundwater resulting from the Cleanup of Groundwater Polluted by Volatile Organic Compounds (VOC), Fuel Leaks, and Other Related Wastes

NPDES Permit No. CAG912002 (VOC and Fuel General Permit)

For the Groundwater Treatment Facility located at:

______

Facility Street Address, City, Zip Code CIWQS Place Identification Number

A PDF electronic copy of this form shall be uploaded on GeoTracker and a confirmation email shall be sent to the responsible staff member at this office, currently Lourdes Gonzales, at .

Table C-1. Mark only one as applicable

1 / Temporary groundwater dewatering project, e.g., during a construction project, has been completed.
2 / Groundwater cleanup work has been completed.
3 / Method of groundwater cleanup has been changed with no need to discharge treated groundwater.
4 / Extract and treat method of groundwater cleanup will be stopped for a while and only monitoring of groundwater will occur at this site. Please attach documentation that the agency overseeing cleanup has no objection to cessation of groundwater extraction and treatment.
5 / Other reason. Please specify below (e.g., discharge to POTW has been granted):

Table C-2. Agency Approval (applicable if Table C-1 row 2, 3, or 4 marked)

Name, address, email, and phone number of the agency and agency staff overseeing the cleanup work / Have you provided a copy of this termination notice to this staff? (Yes/No. If No, please explain the reason)
1

I, the Discharger, certify under penalty of law that this notice is prepared under my direction or supervision and last/final date of this discharge was ______. I am aware that discharging without a discharge authorization is in violation of California Water Code.

______

Name (print) Signature and Date

______

Title/Organization (Discharger’s Organization) Address, email, and phone number

Note: The Regional Water Board may modify this form at any time to reflect new requirements and other needed improvements.

Attachment C –Notice of Termination C-1