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TPDES VI CGP – VIGSA0000 - Notice Of Termination (NOT) Form Page 1 of 3 USVI Department of Planning and Natural Resources Notice of Termination (NOT) for Stormwater Discharges Associated with CONSTRUCTION ACTIVITY under the TPDES VI Construction General Permit (VI CGP) No. VIGSA0000 Submission of this Notice of Termination (NOT) constitutes notice that the operator identified in Section II of this form is no longer authorized to discharge stormwater associated with construction activity under VIDPNR’s TPDES VI CGP 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 1. TPDES Permit Tracking No. 2. Reason for Termination (check one only): a. You have completed earth-disturbing activities at your site, and you have met all other requirements in Part 8.2.1. b. Another operator has assumed control over all areas of the site and that operator has submitted an NOI and obtained coverage under the VI CGP. c. You have obtained coverage under an individual permit or another general TPDES Permit addressing stormwater discharges from the construction site. II. Operator Information 1. Name _____________________________________________________________________________________ 2. IRS Employer Identification Number (EIN): _____________________________________ 3. Mailing Address _____________________________________________________________________________________ _____________________________________________________________________________________ 4. Phone (_____)_______________ 5. Fax: (_____)_______________ 6. Email _____________________________________________________________________________________ 7. Point of Contact (Name): ______________________________________________________________________ TPDES VI CGP – VIGSA0000 - Notice Of Termination (NOT) Form Page 2 of 3 III. Project/Site Information 1. Project/Site Name : _______________________________________________________________________ 2. Project/Site Physical Address __________________________________________________________________________ __________________________________________________________________________ IV. Certifier Name and Title 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. Name: ________________________________________________________________ Title: ________________________________________________________________ Signature: ________________________________________________________________ Date: _____________ Email: __________________________________________________ Instructions for Completing the Notice Of Termination (NOT) for Stormwater Discharges Associated with CONSTRUCTION ACTIVITY under the TPDES VI CGP No. VIGSA0000 Who May File A Notice of Termination (NOT) Form. Permittees who are presently covered under the VIDPNR issued 2012 VI CGP for Stormwater Discharges Associated with Construction Activity may submit an NOT form when: (1) earth- disturbing activities at the site are completed and the conditions in Parts 8.2.1.1 thru 8.2.1.5 are met; or (2) the permittee has transferred all areas under its control to another operator, and that operator has submitted and obtained coverage under this permit; or (3) the permittee has obtained coverage under a different TPDES permit for the same discharges. Completing the Form Please make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the address above. Fees Fees are not due when an NOT is filed. However, timely filing an NOT can decrease the annual discharge fee, which is assessed based on the number of months in a calendar year for which permit coverage was in effect. Where To File NOT Form. NOTs must be sent to one of the following addresses, corresponding with the island on which the construction activity covered is located: STX: VIDPNR Water Pollution Control Program ATTN: TPDES Program 45 Mars Hill Frederiksted, VI 00840 STT & STJ: VIDPNR Water Pollution Control Program ATTN: TPDES Program Charles W. Turnbull Regional Library 4607 Tutu Park Mall St. Thomas, VI 00802 Please submit the original with a signature in ink – Do Not Send Copies. Also, faxed copies will not be accepted. Section I: Permit Number. 1. Enter the TPDES permit tracking number assigned by VIDPNR to the project/site. 2. Indicate your reason for submitting this Notice of Termination by checking the appropriate box. Check only one: You have completed earth-disturbing activities at your site and, if applicable, construction support activities covered by this permit (see Part 1.6.3) and you have met all other requirements in Part 8.2.1. Another operator has assumed control over all areas of the site and that operator has submitted an NOI and obtained coverage under the CGP. You have obtained coverage under an individual permit or another general NPDES permit addressing stormwater discharges from the construction site. Section II: Operator Information 1. Provide the legal name of the person, firm, public organization or any other public entity that operates the project described in this application and is covered by the permit tracking number identified in Section I. Refer to Appendix A of the permit for the definition of “operator”. 2. Provide the employer identification number (EIN from the Internal Revenue Service; IRS). If the applicant does not have an EIN enter “NA” in the space provided. 3. Provide the Mailing Address of the operator. 4. Provide the telephone number of the line at the facility. 5. Provide a fax number (if one exists). 6. Provide an email address available to receive electronic correspondence. Section III: Project/Site Information 1. Provide the project/site’s official or legal name. 2. Provide the project/site’s physical address here. If no physical address exists, indicate the general location and you must provide the GPS coordinates of the main entrance to the project/site. Section IV: Certification Certification statement and signature (see Section 11 of Appendix H of the VI CGP for more information). Enter certifier’s printed name, title and email address. Sign and date the form. (CAUTION: An unsigned or undated NOT form will prevent the granting of permit coverage.) Territorial statutes provide for severe penalties for submitting false information on this application form. Territorial 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 for the corporation, or (ii) the manager of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where 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; or For a municipal, State, Federal, or other public facility: by either a principal executive or ranking elected official. TPDES VI CGP – VIGSA0000 - Notice Of Termination (NOT) Form ADDENDUM TO NOTICE OF TERMINATION EFFECTIVE DATE OF TERMINATION FOR PURPOSES OF DETERMINING 2020 ANNUAL DISCHARGE FEE This addendum is not required, but filing it may decrease or eliminate your 2020 annual discharge fee. Attach this to your Notice of Termination and submit it to DPNR no later than October 1, 2020. TPDES Permit Tracking No. ____________________ I request that my permit coverage be terminated effective [insert date] ______________ because, on or before that date (check one only): ☐ a. I completed earth-disturbing activities at my site, and I have met all other requirements in Part 8.2.1. ☐ b. Another operator has assumed control over all areas of the site and that operator has submitted an NOI and obtained coverage under the VI CGP. ☐ c. I have obtained coverage under an individual permit or another general TPDES Permit addressing stormwater discharges from the construction site. I certify under penalty of law that this document was 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. Name: ________________________________________________________________ Title: ________________________________________________________________ Signature: ________________________________________________________________ Date: _____________ Email: __________________________________________________ EXPLANATION: Starting in 2020, permittees are required to pay an annual discharge fee for each year in which they are covered by a TPDES permit. If a permittee terminates permit coverage by filing a Notice of Termination with DPNR, the annual discharge fee will be prorated. Normally, termination is effective when DPNR receives the Notice of Termination. For example, if a permittee completed construction and all other activities necessary to terminate a permit in January and filed a Notice of Termination on July 1, the permittee would owe a discharge fee for six months of 2020. Because permittees were not previously aware that late filing of a Notice of Termination would affect the fees owed, DPNR is giving permittees this one-time opportunity to request that Notices of Termination become effective on the date of completion of the activities necessary to terminate a permit. Based on accurate information provided in this Addendum and filed with DPNR, 2020 annual discharge fees for terminated permits will be prorated based on when the permit should have been terminated, not when DPNR received the Notice of Termination.