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COLORADO WATER QUALITY CONTROL DIVISION NOTICE OF TERMINATION www.coloradowaterpermits.com 0 DA.0 PERMITTEE 15 NO LONGER THE OWNER /OPERATOR of site and all efforts have been rude to transfer the permit to appropriate parties. (Please attach copies of registered mail receipt, letters, etc.) THE FOLLOWING SHOULD BE KEPT IN MIND IF YOUR PERMIT IS TERMINATED 1. The permittee will still be responsible and subject to any enforcement action for any discharge or spills into state waters. Should the activities covered in the permit continue after the permit has been terminated and discharge needs to occur, you must apply for AND receive a new permit or authorization prior to discharge. It is unlawful to discharge pollutants from a point source to state waters without a permit. Section 25 -8 -608 of the Water Quality Control Act provides for assessing civil penalties of up to $10,000 per day for unlawful discharges. 2. In general, the continued existence of a discharge from a point source to state waters will be the basis for denial of the termination request. PART E. CERTIFICATION SIGNATURE REQUIRED FOR ALL TERMINATION REQUESTS Check the appropriate certification box below if it applies and date and sign form. For SAND & GRAVEL Certifications: I am Requesting and authorizing changing the above listed Sand & Gravel Certification (currently under General Permit COG500000) to a Stormwater only certification (under General Permit COR340000). I 1 For STORMWATER INDUSTRIAL Certifications: I certify that all industrial activity at the identified site has ceased; all potential pollutant sources have been removed; all industrial wastes have been disposed of properly and all elements of the Stormwater Management Plan have been completed. For WASTE WATER Certifications: I certify that all Wastewater previously authorized for Discharge by the Division has been properly disposed of and all discharges have ceased FOR ALL PERMITS, CERTIFICATIONS, AND AUTHORIZATIONS I certify that all annual reports, discharge monitoring reports, and /or other reporting paperwork for the period prior to the termination date of the permit, certification, or authorization have been submitted. I certify under penalty of law that this document and all attachments were prepared under my direction and /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 of the person or persons who manage the system, or those individuals immediately 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. " (See 18 USC 1001 and 33 USC 1319) I also certify that I am the legal representative of the above named company. ure of Legally Responsible Party N 7 ZC( Name (printed) Title Date Signed N Signatory requirements: This termination request shall be signed, dated, and certified for accuracy by the permittee in accord with the following criteria: 1. In the case of a corporation, by a principal executive officer of at least the level of vice - president, or his or her duly authorized representative, if such representative is responsible for the overall operation of the operation from which the discharge described herein originates; 2. In the case of a partnership, by a general partner; 3. In the case of a sole proprietorship, by the proprietor; 4. In the case of a municipal, state, or other public operation, by wither a principal executive officer, ranking elected official, or other duly authorized employee. Page 5 of 5 forma last revised March 2010