Notice of Termination Form
Industrial Activity MNR050000
Doc Type: Notice of Termination
Instructions: Use this form to terminate your Minnesota Pollution Control Agency (MPCA) Industrial Stormwater Permit or No Exposure exclusion.Print a copy of the completed form for your records, or save the completed form to your computer in a location where you can easily find it.Do not use this form to change from general permit coverage to no exposure exclusion status or vice versa;submit a new permit application to make those changes.
Submittal: The person who certifies this form can email the completed form tousing “Notice of Termination Form” as the subject line. A manual confirmation email will be sent. If you do not receive anemail confirmation within two business days, please contact us.
Questions: Email the program at or call the Stormwater Hotline at: 651-757-2119 or
800-657-3804 (non-metro only).
Facility Information (as listed on the original permit application form)
Facility name: / Date:Facility address: / Permit number:
City: / State: / Zip code:
Contact name: / Contact phone:
Reason for Termination
1.Facility closed: Industrial activity has ceased and all contact between stormwater and significant materials has been eliminated. Do not terminate your permit until all activities at the site have ended and all indoor and outdoor materials have been removed from the facility.
2.Different type of stormwater permit: You have received anindividual National Pollutant Discharge Elimination System (NPDES)/State Disposal System (SDS) Permit or industry-specific NPDES/SDS Permit for stormwater discharges.
3.Other (please describe):
Certification
Federal and state regulations require the authorized signer to be:
A.Corporation: a principal executive officer of at least the level of vice president.
B.Partnership or sole proprietorship: a general partner or the proprietor, respectively.
C.Municipality, state, federal, or other public facility: a principal executive officer or ranking executive official.
D.If the operator of the facility is different than the owner, both the operator and the owner must sign.
I understand that the submittal of this request for termination does not release me 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 gathered and evaluated 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 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.
By typing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form.
Owner authorized signature: / Operator authorized signature (if different):Name: / Name:
(This document has been electronically signed.) / (This document has been electronically signed.)
Title: / Title:
Date (mm/dd/yyyy): / Date (mm/dd/yyyy):
651-282-5332 or 800-657-3864•Available in alternative formats
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