DWQ-2023-200084

STATE OF UTAH, DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WATER QUALITY195 North 1950 West, P.O. Box 144870, Salt Lake City, Utah 84114-4870 [phone]
NOTNotice of Termination (NOT) for Storm Water Discharges Associated with Industrial Activity Under the UPDES MultiSector General Permit.
INSTRUCTIONS ON BACK
Submission of this Notice of Termination constitutes notice that the party identified in Section II of this form is no longer authorized to discharge storm water associated with industrial
activity under the UPDES program. ALL NECESSARY INFORMATION MUST BE PROVIDED ON THIS FORM.
I.PERMIT INFORMATION
Permit Number: __________________
Reason for Termination A new owner or operator has taken over responsibility for the facility. You have ceased operations at the facility, there are not or no longer will be discharges
of stormwater associated with industrial activity from the facility. You obtained coverage under an individual or alternative general permit for all discharges required to be covered
by an UPDES permit. You have applied for either a "no exposure" or "no discharge" exclusion from permit coverage.
Other: ___________________________________________________________________________________________________________II.OWNER/OPERATORINFORMATIONCheck here if Operator Information is the
same as Owner Information
Owner Name: ______________________________________________________________________________________________
Address: __________________________________________________________________________________________________
City: ______________________________________________________ State:______ Zip: __________________________
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OPERATOR INFORMATION(Do not fill out if Operator is same as Owner)
Operator Name: ____________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________________
City: ______________________________________________________ State: ______ Zip: __________________________III.FACILITY SITE/LOCATION INFORMATIONFacility Name: _____________________________________________________________________________________________
Address: ____________________________________________________________ County: ____________________________
City: ______________________________________________________ State: ______ Zip: __________________________
IV. CERTIFICATION
I certify under penalty of law that all storm water discharges associated with industrial activity from the identified facility that are authorized by a UPDES general permit have been
eliminated or that I am no longer the operator of the industrial activity. I understand that by submitting this Notice of Termination, I am no longer authorized to discharge storm water
associated with industrial activity under this general permit, and that discharging pollutants in storm water associated with industrial activity to waters of the State is unlawful under
the State of Utah Water Quality Act where the discharge is not authorized by a UPDES permit. I also understand that the submittal of this Notice of Termination does not release an operator
from liability for any violations of this permit or the Water Quality Act.
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 gather and evaluate 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:Title:Email:Phone:Signature:Date:
For office use only:
Enter the contact information of user who transcribed the information from the paper form into the MSGP applicationName:Organization: Email:Phone:
INSTRUCTIONSNotice of Termination (NOT) For Permit Coverage Under the UPDES Multi-Sector General Permit (MSGP)Who Must File A Notice of Termination (NOT) Form
Permittees who are presently covered under the State issued Utah Pollutant Discharge Elimination System (UPDES) General Multi-Sector Permit for Storm Water Discharges Associated with
Industrial Activity may submit a Notice of Termination (NOT) form when their facilities no longer have any storm water discharges associated with industrial activity as defined in the
storm water regulations at UAC R317-8-11.3(6)(d), or when they are no longer the operator of the facilities. If you have questions, contact the Storm Water Section of the Division of
Water Quality at [phone].Where To File NOT Form The preferred method of submitting a NOT is by completing a NOT electronically on the NPDES eReporting Tool (NeT) Storm Water
Database: https://cdx.epa.gov/ . If you submit a waiver from electronic reporting, in accordance with Part I.I of the permit, you may also submit a paper form to the following address:Department
of Environmental QualityDivision of Water QualityP.O. Box 144870Salt Lake City, UT 84114-4870SECTION I – PERMIT INFORMATIONEnter the existing UPDES Storm Water General Permit number
assigned to the facility or site identified in Section III. If you do not know thepermit number, contact the Division of Water Quality at [phone].Indicate your reason for submitting
this Notice of Termination by checking the appropriate box. If the reason for termination is not listed, check “Other” and write in the reason in the space provided.SECTION II – OWNER
AND OPERATOR INFORMATIONSupply the legal name(s) of the person(s), firm(s), public organization(s), or any other entity(ies) that qualifies as the owner of the project (see permit definitions).
Do the same for the operator that conducts facility operations at the permitted site. The owner and the operator of the project may be the same.Enter the complete address and telephone
number of the owner and operator and a point of contact person and number for each. SECTION III – FACILITY INFORMATION Enter the facility name of the site and complete street address,
including city, state and ZIP code. SECTION IV – CERTIFICATION State statutes provide for severe penalties for submitting false information on this application form. State regulations
require this application to be signed as follows:For a corporation:by a responsible corporate officer, which means: (i) president, secretary, treasurer, or vice-president of the corporation
in charge of a principal business function, or any other person who performs similar policy or decision making functions, or (ii) the manager of one or more manufacturing, production,
or operating facilities employing more than 250 persons or having gross annual sales or expenditures exceeding $25 million (in second quarter 1980 dollars), if authority to sign documents
has been assigned or delegated to the manager in accordance with corporate procedures;For a partnership or sole proprietorship: by a general partner or the proprietor; orFor a municipality,
state, Federal, or other public facility: by either a principal executive officer or ranking elected official.