Notice Of Termination - Montana Department Of Environmental Quality Page 2
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1
2Section E - Explanation
Indicate the reason for the termination of above referenced permit by checking the most appropriate box, and provide a
detailed description in the space provided below:
Discharge terminated or will be terminated by DATE ____________________;
Discharge permanently terminated by connection to a wastewater treatment plant (WWTP);
Date discharge connected or will connect to WWTP: _______________________________
Provide name and MPDES permit number of WWTP:__________________________
Other________________________________________________________
Please provide a detailed explanation in the space below (attach additional pages if needed) of why the
permit/authorization is no longer needed. Please refer to the Standard Conditions section of your permit and include any
information specified in your permit required for permit termination.
Section F - CERTIFICATION
Permittee Information: This form must be completed, signed, and certified as follows:
•
For a corporation, by a principal officer of at least the level of vice president;
•
For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or
•
For a municipality, state, federal, or other public facility, by either a principal executive officer or ranking elected
official.
All Applicants Must Complete the Following Certification
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 on my inquiry of the 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. [75-5-633, MCA]
A. Name (Type or Print)
B. Title (Type or Print)
C. Phone No.
D. Signature
E. Date Signed
Return this form (NOT)
to:
Department of Environmental Quality
Water Protection Bureau
P.O. Box 200901
Helena, MT 59620-0901
(406) 444-3080
Version 2.1 August 2015
Notice of Termination Form
Page 2 of 2
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