Form Cn 1175 – Fill Out and Use This PDF

TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION (TDEC)

Division of Water Resources

William R. Snodgrass Tennessee Tower, 312 Rosa L. Parks Avenue, 11th Floor, Nashville, Tennessee 37243

1-888-891-TDEC (8332)

Notice of Termination (NOT) for General NPDES Permit for Stormwater Discharges from Construction Activities (CGP)

This form is required to be submitted when requesting termination of coverage from the CGP. The purpose of this form is to notify the TDEC that either all stormwater discharges associated with construction activity from the portion of the identified facility where you, as an operator, have ceased or have been eliminated; or you are no longer an operator at the construction site. Submission of this form shall in no way relieve the permittee of permit obligations required prior to submission of this form. Please submit this form to the local DWR Environmental Field Office (EFO) address (see table below). For more information, contact your local EFO at the toll-free number 1-888-891-8332 (TDEC).

Type or print clearly, using ink.

	Site or Project Name:		NPDES Tracking
			Number: TNR

Name of Permittee Requesting Termination of Coverage:

Permittee Contact Name:	Title or Position:
Mailing Address:	City:	State:	Zip:
Phone:	E-mail:

Check the reason(s) for termination of permit coverage:

Stormwater discharge associated with construction activity is no longer occurring and the permitted area has a uniform 70% permanent vegetative cover OR has equivalent measures such as rip rap or geotextiles, in areas not covered with impervious surfaces.

You are no longer the operator at the construction site (i.e., termination of site-wide, primary or secondary permittee coverage).

Certification and Signature: (must be signed by president, vice-president or equivalent ranking elected official)

I certify under penalty of law that either: (a) all stormwater discharges associated with construction activity from the portion of the identified facility where I was an operator have ceased or have been eliminated or (b) I am no longer an operator at the construction site. I understand that by submitting this notice of termination, I am no longer authorized to discharge stormwater associated with construction activity under this general permit, and that discharging pollutants in stormwater associated with construction activity to waters of the United States is unlawful under the Clean Water Act where the discharge is not authorized by a NPDES 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 Clean Water Act.

For the purposes of this certification, elimination of stormwater discharges associated with construction activity means that all stormwater discharges associated with construction activities from the identified site that are authorized by a NPDES general permit have been eliminated from the portion of the construction site where the operator had control. Specifically, this means that all disturbed soils at the portion of the construction site where the operator had control have been finally stabilized, the temporary erosion and sediment control measures have been removed, and/or subsequent operators have obtained permit coverage for the site or portions of the site where the operator had control.

I certify under penalty of law that this document and all attachments were prepared by me, or under my direction or supervision. The submitted information 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. As specified in Tennessee Code Annotated Section 39-16-702(a)(4), this declaration is made under penalty of perjury.

CN-1175 (Rev. 12-14)

RDA 2366