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