Notice Of Termination - Montana Department Of Environmental Quality
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1
2AGENCY USE ONLY
PERMIT NO.:
Date Rec’d.:
Amount Rec’d.:
Check No.:
Rec’d By:
WATER
PROTECTION
BUREAU
FORM
Notice of Termination
Non-Storm Water General Permit Authorizations
NOT
This form is to be submitted when a discharge permit is no longer required or necessary. The Montana Department of
Environmental Quality (DEQ) will notify the permittee in writing of the date termination is effective. This form may not
be used to request termination of coverage under any storm water general permit. You must type or print legibly; forms
that are not legible or are unsigned will be returned. Do not leave blank spaces. It is recommended that you maintain a
copy of the completed form for your records.
Section A - Site Information
Permit/Authorization Number: MTG __ __ __ __ __ __
Facility or Site Name:
Facility or Site Location (physical address or Township/Range/Section):
Facility or Site Mailing Address (if available)_____________________________________________________
Nearest City or Town ___________________ State________ Zip Code___________ County_______________
Latitude: _____________________ Longitude:
Section B - Owner/Operator (Regulated Entity) Information
Owner/Operator Name:
Signatory Name and Position Title:
Mailing Address:
City:
State:
Zip Code:
Phone:
Email:
Section C - Annual Fees
There are no fees associated with terminating permit coverage. However, the permittee is responsible for payment of
annual fees for each calendar year in which the discharge is authorized, and annual fees are billed in arrears. You may
contact DEQ at (406) 444-3080 to receive an invoice for the outstanding annual fees associated with your effective permit
coverage, or one will be mailed to you.
Section D – Required Reports
You are required to comply with all conditions and reporting requirements until notified by DEQ that your general permit
authorization is terminated, including submission of Discharge Monitoring Reports.
Version 2.1 August 2015
Notice of Termination Form
Page 1 of 2
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