DWQ-2025-000180

Construction Oversight Notice of Termination Form
BACKGROUND INFORMATION
Site Name: UPDES Permit #:
Site Address:
Local Jurisdiction or County:
Permit Effective Date: Permit Expiration Date:
Total Project Area: Total Disturbed Area:
Project Type: (circle) Subdivision Commercial Industrial Linear (Road/Pipe/Power) Land Disturbance
OPERATOR CONTACT INFORMATION
NAMES PHONE NUMBERS E-MAIL
Operator:
Onsite Facility Contact:
Important Contacts:
Important Contacts:
NOTICE OF TERMINATION (NOT) INSPECTION
Inspected By: Date of Evaluation:
Title\Organization:
List:
Yes, No, N/A
1. Has the site achieved final stabilization? (>70% vegetative and/or non-vegetative cover for all disturbed areas) (CGP 8.2.1.a, 2.2.14.b; CPP 1.7.1)*
2. Have all construction materials, waste and waste handling devices been removed? (CGP 8.2.1.b; CPP 2.4)
3. Have all temporary storm water controls been removed? (CGP 8.2.1.c)
4. Have all pollutants and pollutant-generating activities been removed? (CGP 8.2.1.d; CPP 2.8, 2.9)
5. If landscaping will be completed by the homeowner, have temporary sediment and erosion controls been installed? (CGP 8.2.4; CPP 1.7.2)
*Provide comments for exceptions under CGP 2.2.14.b(3) (arid conditions, restored ag. land, or areas to remain disturbed).
COMMENTS:

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.

Inspector:
(Print Name) (Title) (Signature) (Date)

Operator:
(Print Name) (Title) (Signature) (Date)
modified 01/25