Form 606-003 - Notice Of Termination printable pdf download

NOTICE OF TERMINATION

DEQ

OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY

NOTICE OF TERMINATION (NOT) FOR STORM WATER DISCHARGES

FORM

ASSOCIATED WITH INDUSTRIAL OR CONSTRUCTION ACTIVITY

606-003

UNDER AN OPDES GENERAL PERMIT

Sept. 13, 2012

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

authorized to discharge storm water associated with industrial or construction activities under the OPDES program.

All Requested Information Must Be Provided on This Form. See Instructions On The Back Of Form.

I. Permit Information:

OPDES

Check here if you are no longer the

Check here if the storm water construction

Storm Water General Permit Authorization

operator of the facility/site:

or industrial discharge is being terminated:

Number:





______________________________

II. Facility/Site Operator Information:

Name: ___________________________________________ Phone: _____________________________

Address:______________________________________________________________________________

City: _____________________________ State: _________________ Zip Code: _____________________

III. Facility/Site Location:

Name:__________________________________________________________________________

Address: ________________________________________________________________________

City: __________________________________ State: __________________________ Zip Code:________________

Latitude:

Longitude:________________

IV. New Facility/Site Information:

If you are no longer the operator of the facility/site, provide the following information pertaining to the new operator at

the facility/site:

Name:______________________________________________________________________________

Address: ____________________________________________________________________________

City: ______________________________ County: _____________________ Zip Code:_____________

V. Certification:

I certify under penalty of law that all storm water discharges associated with industrial/construction activity from the

identified facility/site that were authorized by a general permit have been eliminated or that I am no longer the operator

of the facility/site. I understand that by submitting this Notice of Termination, I am no longer authorized to discharge

storm water associated with industrial or construction activity under this general permit, and that discharging pollutants in

storm water associated with industrial or construction activity to waters of the State is unlawful under the Clean Water

Act and OAC 252:606-1-3(b)(3)(L) where the discharge is not authorized by an OPDES permit. I also understand that the

submittal of this Notice of Termination does not release me as an operator from liability for any violations of this permit

or the Clean Water Act.

Print Name: _______________________________________________________

Date:____________________

Signature:____________________________________________________

Title___________________________

Form 606-003 - Notice Of Termination

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