Co Permittee Liability Release Form For Permits printable pdf download

Co Permittee Liability Release Form For Permits

3150-FM-BWEW0271

10/2015

COMMONWEALTH OF PENNSYLVANIA

OFFICIAL USE ONLY

DEPARTMENT OF ENVIRONMENTAL PROTECTION

BUREAU OF WATERWAYS ENGINEERING AND WETLANDS

CO-PERMITTEE LIABILITY RELEASE FORM FOR PERMITS

ASSOCIATED WITH 25 PA CODE CHAPTER 102

Applicability: This form may be used by a permittee or co-permittee presently covered under an Individual National

Pollutant Discharge Elimination System (NPDES) Permit for Stormwater Discharges Associated with Construction

Activities, the General NPDES Permit for Stormwater Discharges Associated with Construction Activities (PAG-02), an

Erosion and Sediment Control Permit (ESCP), or an Erosion and Sediment Control General Permit for Earth Disturbance

Associated with Oil and Gas Exploration, Production, Processing, or Treatment Operations or Transmission Facilities

(ESCGP) regardless of when the permit was issued or authorized.

Who May File a Co-Permittee Liability Release Form:

Permittees or Co-permittees, presently covered under a permit referenced above, may submit this release form to the

Department of Environmental Protection (Department) or conservation district when the co-permittee is no longer an

operator of the construction activity at an unstabilized site.

PERMIT INFORMATION:

Permit No.:

EARTH DISTURBANCE SITE LOCATION:

Facility/Development Name:

Address :

Municipality:

County:

Latitude: / '/ "

Longitude: / '/ "

U.S.G.S. Quad Map Name:

PERMITTEE ACKNOWLEDGEMENT:

Organization/Individual Name:

Address:

City:

State:

Zip Code:

Telephone Number:

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Co Permittee Liability Release Form For Permits