Form Ecy 020-86 - Notice Of Termination Form Industrial Stormwater General Permit
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1
2Notice of Termination Form
. Permit # WAR -
______
Industrial Stormwater General Permit
I
Use this form to request termination of permit coverage
II. FACILITY ADDRESS
III. BILLING ADDRESS
Facility Name
Company Name
Street Address
Contact Name
City
Zip + 4
Street Address
County
PO Box
Zip+ 4
Phone No. of Primary Contact Person
City
Operator/Primary Contact Person
Phone No.
Legal Description (if no address for facility)
IV. JUSTIFICATION FOR TERMINATION
Provide a brief description justifying termination. (Be sure to include date operations ceased.)
V.
CERTIFICATION OF PERMITTEE(S)
“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 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.”
_______________________________________________
Operator’s Printed Name / Title
_____________________________________________________
Operator’s Signature
_____________________________________________________
Date
ECY 020-86 (Rev. 08/12)
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