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STATE OF COLORADO <br />FOR DIVISION USE ONLY <br />CERTIFICATION NUMBER FOR <br />PERMITS CONVERTED TO <br />STORMWATER ONLY <br />COLORADO WATER QUALITY CONTROL DIVISION NOTICE OF TERMINATION <br />Please print or type all information. Mail original form with ink signatures to the following address. Emailed and Faxed forms will <br />not be accepted. All items must be filled out completely and correctly. If the form is not complete, it will be returned <br />Colorado Dept of Public Health and Environment <br />Water Quality Control Division <br />4300 Cherry Creek Dr South WQCD -P -B2 <br />Denver, CO 80246 -1530 <br />PART A . IDENTIFICATION PERMIT /CERTIFICATION AUTHORIZATION TYPE & TERMINATION PROCESS APPLIED BY THE DIVISION <br />PLEASE LIMIT SUBMISSION TO ONE PERMIT OR CERTIFICATION / FORM <br />All Permit Termination Dates are Effective on the date approved by the Division. <br />Please write the anrooriate number in the blank Drovided to the left of the Dermit /certification tvne. <br />1. INDIVIDUAL PERMIT <br />� r Oi� <br />Dedicated to protecting and improving the health and environment of tho people of Colorado <br />COG070000 <br />43GD Cherry Creek Dr. 5_ <br />Cert/Facility Number <br />Denver, Colorado 60246.1530 <br />F fggg <br />Phone(303)692 -2400 <br />COG588000 <br />TDD L ine (303) 691 - 7700 <br />Colorado Dep artment <br />Located in Glendale, Colorado <br />of Public t lealth <br />hlip,llwww.cdphe.stafe.co.us <br />and Environment <br />FOR DIVISION USE ONLY <br />CERTIFICATION NUMBER FOR <br />PERMITS CONVERTED TO <br />STORMWATER ONLY <br />COLORADO WATER QUALITY CONTROL DIVISION NOTICE OF TERMINATION <br />Please print or type all information. Mail original form with ink signatures to the following address. Emailed and Faxed forms will <br />not be accepted. All items must be filled out completely and correctly. If the form is not complete, it will be returned <br />Colorado Dept of Public Health and Environment <br />Water Quality Control Division <br />4300 Cherry Creek Dr South WQCD -P -B2 <br />Denver, CO 80246 -1530 <br />PART A . IDENTIFICATION PERMIT /CERTIFICATION AUTHORIZATION TYPE & TERMINATION PROCESS APPLIED BY THE DIVISION <br />PLEASE LIMIT SUBMISSION TO ONE PERMIT OR CERTIFICATION / FORM <br />All Permit Termination Dates are Effective on the date approved by the Division. <br />Please write the anrooriate number in the blank Drovided to the left of the Dermit /certification tvne. <br />1. INDIVIDUAL PERMIT <br />Permit Number <br />Termination for an individual permit generally requires inspection by the Division to ensure discharges <br />COG070000 <br />have ceased; has a 30 day Public Notice Period prior to termination approval; and may require bond <br />Cert/Facility Number <br />release for mining discharge permits. Termination for these permits also require up to date submissions <br />COG603000 <br />of all annual reports, discharge monitoring reports, or other reporting paperwork for the period prior to <br />COG588000 <br />the termination date of the permit. <br />COG604000 <br />• PRETREATMENT Generally requires inspection by the Division to ensure discharges have ceased. <br />Permit Number <br />Termination for these permits also require up to date submissions of all annual reports, discharge <br />COG607000 <br />monitoring reports, or other reporting paperwork for the period prior to the termination date of the <br />COG600000 <br />permit. <br />COR010000 <br />2. CERTIFICATION UNDER A GENERAL PERMIT <br />a. Termination for certifications under one of these general permits is based on self - certifying information <br />Termination for these certifications also require up to dote submissions of all annual reports, discharge monitoring reports, or <br />b. Termination for certifications under one of these general permits generally requires an inspection by the Division to ensure <br />discharges have ceased. Termination for these certifications also require up to date submissions of all annual reports, <br />aiscnarge monitoring reports, or other reporting paperworx for the period prior to the termination date of the permit. <br />1. <br />orner reporting paperworx for me perjoa prior ro me rerminarron Aare of me permit. <br />1. <br />COG070000 <br />Construction De- watering. <br />Cert/Facility Number <br />2. <br />COG603000 <br />Subterranean Dewatering or Well development <br />COG588000 <br />3. <br />COG604000 <br />Hydrostatic Testing <br />COG589000 <br />4. <br />COG607000 <br />Commercial Washing of Outdoor Structures <br />COG600000 <br />5. <br />COR010000 <br />Light Industry Activities — Stormwater <br />COG605000 <br />6. <br />COR020000 <br />Heavy Industry Activities — Stormwater <br />COG641000 <br />7. <br />COR060000 <br />Recycling Industry Activities — Stormwater <br />COG840000 <br />8. <br />NOX000000 No Exposure Exclusion - - Stormwater <br />9. <br />b. Termination for certifications under one of these general permits generally requires an inspection by the Division to ensure <br />discharges have ceased. Termination for these certifications also require up to date submissions of all annual reports, <br />aiscnarge monitoring reports, or other reporting paperworx for the period prior to the termination date of the permit. <br />1. <br />COG130000 <br />Aquatic Animal Production <br />Cert/Facility Number <br />2. <br />COG315000 <br />Groundwater Remediation <br />3. <br />COG588000 <br />Domestic WWTF 100:1 Dilution <br />4. <br />COG589000 <br />Domestic WWTF Surface Water <br />5. <br />COG600000 <br />Minimal Industrial Wastewater Discharge <br />6. <br />COG605000 <br />Non- Contact Cooling Water <br />7. <br />COG641000 <br />Water Treatment Plant Wastewater Discharges <br />8. <br />COG840000 <br />Produced Water Treatment Facility <br />9. <br />COX621000 <br />Domestic Wastewater Treatment > 2000gpd — Groundwater <br />10, <br />COX622000 <br />Domestic WW Treatment -no GW Monitoring Requirements - Groundwater <br />11. <br />COX631000 <br />Domestic WW Treatment System — Land Disposal - Groundwater <br />12. <br />COX632000 <br />Domestic WW Treatment System — Land Treatment - Groundwater <br />13. <br />COX633000 <br />Domestic WW Treatment System — Land Treatment /Agronomic rate — Groundwater <br />Page 1 of 5 form last revised March 2010 <br />