Fillable Notice Of Termination (Not) Of Coverage Template printable pdf download

This Form Replaces Form 3517-7 (8-98)

Form Approved OMB Nos. 2040-0086 and 2040-0211

Refer to the Following Page for Instructions

United States Environmental Protection Agency

NPDES

Washington, DC 20460

FORM

Notice of Termination (NOT) of Coverage Under an NPDES General Permit for

Stormwater Discharges Associated with Construction Activity

Submission of this Notice of Termination constitutes notice that the party identified in Section II of this form is no longer authorized to

discharge stormwater associated with construction activity under the NPDES program from the site identified in Section III of this form. All

necessary information must be included on this form. Refer to the instructions at the end of this form.

I. Permit Information

NPDES Stormwater General Permit Tracking Number:

Reason for Termination (Check only one):

Final stabilization has been achieved on all portions of the site for which you are responsible.

Another operator has assumed control, according to Appendix G, Section 11.C of the CGP, over all areas of the site that have not been

finally stabilized.

Coverage under an alternative NPDES permit has been obtained.

For residential construction only, temporary stabilization has been completed and the residence has been transferred to the homeowner.

II. Operator Information

Name:

IRS Employer Identification Number (EIN):

–

Mailing Address:

Street:

City:

State:

Zip Code:

Phone:

Fax (optional):

E-mail:

III. Project/Site Information

Project/Site Name:

Project Street/Location:

City:

State:

Zip Code:

County or similar government subdivision:

IV. Certification Information

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, 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.

Print Name: ______________________________________________________________________________________________________

Print Title: ________________________________________________________________________________________________________

Email: __________________________________________________________________________________________________________

Signature: _______________________________________________________________________________________________________

Date: ___________________________________________________________________________________________________________

EPA Form 3510-13 (Rev. 12/08)

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Notice Of Termination (Not) Of Coverage Template

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