Industrial Notice of Termination

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					                                                                                                                             For Official Use Only

                                                                 State of Georgia
                                                          Department of Natural Resources

                                                               Notice of Termination
                                                        General Permit No. GAR000000
                                                 Storm Water Associated With Industrial Activity
G Change of Owner / Operator               G Facility Closed         G Other


FACILITY NAME:                                                                                          PHONE:



CITY:                                                               COUNTY:                                      ZIP CODE:


LEGAL NAME:                                                                                             PHONE:


CITY:                                                               STATE:                              ZIP CODE:

          G Private        G Public       [ G State     G Federal        G County/City ]

FACILITY CONTACT: Name:                                                                                     Title:

                           Telephone Number:


SIC CODES: Primary:                                      Secondary:

          AND / OR          G Hazardous Waste TSD          G Landfill      G Wastewater Treatment             G Power Generation

LATITUDE:              E              ‘           “   LONGITUDE:              E            ‘             “ (E = degrees; ‘ = minutes; “ =


V. CERTIFICATION: I certify under penalty of law that all storm water discharges associated with industrial activity from the identified facility
that are authorized by the General NPDES Permit No. GAR000000 have been eliminated, the identified facility has closed, or the owner-operator of
the identified facility has changed. I understand that by submitting this Notice of Termination, that 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 of Georgia is unlawful under the Georgia Water Quality Control Act and the Clean Water Act where the discharge is not authorized by
a NPDES permit. 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 upon 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.

Printed Name:                                                                                  Title:

Signature:                                                                                     Date:

                                                                    Type All Information
See instructions on Reverse   Version 5/99
                                 Notice of Termination (NOT) For Storm Water Discharges
                                            Associated With Industrial Activity
                                         NPDES General Permit No. GAR000000

Who must file a Notice of Termination (NOT) Form
This Notice of Termination must be typed. Any NOT that contains illegible information will not be accepted. All
information on this NOT must be submitted to be a valid notice. Information requested on the NOT that is not applicable
to the owner-operator or the facility must be marked “N/A”. Please do not leave any blanks.
In situations where all storm water discharges associated with industrial activity that are authorized by the General NPDES
Permit No. GAR000000 have been eliminated or the regulated industrial activity conducted by the permittee at the
identified facility has ceased (facility closure, change of operator, etc), the permittee must submit this NOT. By
submitting this NOT, the permittee (operator/owner) certifies that all storm water discharges have ceased, the facility
is no longer required to have a NPDES permit for the storm water discharges, the facility is no longer operated by the
permittee, or similar circumstances exist at the facility.
If you have questions regarding NPDES Storm Water Permitting, contact the Storm Water Unit of the NonPoint Source
Program at (404) 675-6240.

Where to file. NOTs must be sent to:        Georgia Environmental Protection Division
                                            NonPoint Source Program
                                            4220 International Parkway, Suite 101.
                                            Atlanta, Georgia 30354
Section I. Facility Information: Enter the facility’s name, street address, mailing address, county, and telephone number.
Should the facility lack a street address, describe where the facility is located in “Section IV. Comments.” Indicate the
reason why this NOT is being submitted. Should “other” be marked, indicate why in the “Section IV. Comments”.
Section II. Facility Owner-Operator Information: Enter the owner-operator’s legal name, mailing address and telephone
number. Enter the name, title, and the telephone number of the individual who will serve as the facility contact. Indicate
by marking the appropriate block whether the facility is operated by a private or public entity. For public entities indicate
whether the operator is a state, a federal or a local government.
Section III. Facility Activity Information: List the primary 4-digit standard industrial classification (SIC) code that best
describes the principal products or services provided by the facility identified in Section I. Also enter up to three additional
SIC codes that identify secondary products or services. Mark the applicable block indicating whether this facility is: a
hazardous waste treatment, storage, or disposal facility; a landfill, land application site, or open dump; a municipal or
domestic sewage or sewage sludge treatment works with a design capacity of one (1) million gallons per day; and/or a
steam electric power generation facility.
Provide the latitude and longitude of the approximate center of the facility to the nearest 15 seconds. This information
can be obtained by consulting a United States Geological Service topographical map.
Section IV. Comments: Provide comments as appropriate.
Section V. Certification: Provide the information requested and sign the NOT. Federal and State regulations require this
NOT to be signed by one of the following people:
        For a corporation: by a responsible corporate officer;
        For a partnership or sole proprietorship: by a general partner or the proprietor; or
        For a municipality, state, Federal or other public facility: by either a principal executive officer or ranking elected
Signature of the NOT by parties other than the above does not constitute a valid NOT submittal.