RULE 5 – NOTICE OF TERMINATION (NOT) State Form 51514 (R2 / 4-10) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY For questions regarding the requirements for project termination or completion of this form, contact: Indiana Department of Environmental Management Storm Water, Permits Coordinator 100 North Senate Avenue MC 65-42, Room 1255 Indianapolis, Indiana 46204-2251 Telephone (317) 233-1864 or (800) 451-6027(within Indiana), ext. 31864 Web Access: http://www.IN.gov/idem/4902.htm Note: Submission of this Notice of Termination letter is a certification by the project site owner that the project meets the terms and conditions of the General Permit Rule 327 IAC 15-5 (Rule 5, Storm Water Discharges Associated with Construction Activity) for termination of permit coverage under the National Pollutant Discharge Elimination System (NPDES). PROJECT NAME AND LOCATION Permit number (Note: Permit numbers were assigned to projects beginning in November of 2003. Therefore, a permit number is only applicable for those projects that began or were renewed on or after November of 2003). Project name (Note: Provide the project name as it appears on the active “Notice of Intent”) County Company name Project site owner’s name (an individual) Address (number and street) City State Telephone FAX ZIP code E-mail address (if available) THIS “NOTICE OF TERMINATION” IS BEING SUBMITTED FOR THE FOLLOWING To be eligible for termination, specific criteria must be met. There are three options for which a project may be considered for termination. These options include: • Option # 1 Certification for change of ownership; • Option # 2 Certification for termination of construction activities (327 IAC 15-8); and, • Option # 3 Notice of termination to obtain early release from compliance with 327 IAC 15-5 (327 IAC 15-8). Select one of the three options that apply to “Permit Termination” by checking the appropriate box, complete all information associated with that option, include required attachments (where applicable), and complete the “Project Site Owner Responsibility Statement” on page 2 of this form. Option # 1 Certification for change of ownership This option does not apply to the sale of individual lots within the permitted acreage; only the sale of the entire project site as originally permitted. The agency may accept termination for entire sections or phases of a project that are sold. To determine if a project is eligible, please contact the IDEM Storm Water Permits Coordinator. By signing this “Notice of Termination” , I certify the following: A. The project was sold; I am no longer the project site owner as was designated in my “Notice of Intent”. The new owner of the project site is: Company name (If applicable) Project site owner’s name (An individual) Address (number and street) City Telephone number B. State ZIP code FAX E-mail Address (If available) I have notified the new project site owner of his/her responsibilities to comply with 327 IAC 15-5 and the requirements associated with the rule including filing a new “Notice of Intent.” Option # 2 Certification for termination of construction activities By signing this “Notice of Termination”, I certify the following: A. B. C. All land disturbing activities, including construction on all building lots, have been completed and the entire site has been stabilized; All temporary erosion and sediment control measures have been removed; and No future land disturbing activities will occur at the project site. (Continued on reverse side) American LegalNet, Inc. www.FormsWorkFlow.com Option # 3 “Notice of Termination” to obtain early release from compliance with 327 IAC 15-5 By signing this “Notice of Termination,” I certify the following: A. B. C. D. E. The remaining, undeveloped acreage does not exceed five (5) acres, with contiguous areas not to exceed one (1) acre. A map of the project site, clearly identifying all remaining undeveloped lots, is attached to this letter. The map must be accompanied by a list of names and addresses of individual lot owners or individual lot operators of all undeveloped lots. All public and common improvements, including infrastructure, have been completed and permanently stabilized and have been transferred to the appropriate local entity. The remaining acreage does not pose a significant threat to the integrity of the infrastructure, adjacent properties, or water quality. All permanent storm water quality measures have been implemented and are operational. Upon written notification to the department the project site owner certifies that he/she will: A. Notify all current individual lot owners and all subsequent lot owners of the remaining undeveloped acreage and acreage with construction activity that they are responsible for complying with section 7.5 of 327 IAC 15-5. The notice must inform the individual lot owners of the requirements to: (1) install and maintain appropriate measures to prevent sediment from leaving the individual building lot; and (2) maintain all erosion and sediment control measures that are to remain on-site as part of the construction plan. PROJECT SITE OWNER RESPONSIBILITY STATEMENT By signing this “Notice of Termination” letter, 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 on 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 of project site owner Signature of project site owner ____________________________________________________ Date _________________ This “Notice of Termination” must be signed by an individual meeting the signatory requirements in 327 IAC 15-4-3(g). SUBMITTAL OF THE “NOTICE OF TERMINATION” Please submit the completed “Notice of Termination” to the Indiana Department of Environmental Management (IDEM). A copy of the “Notice of Termination” is required to also be submitted to the Soil and Water Conservation District (SWCD) or a Municipal Separate Storm Sewer System (MS4). The appropriate entity will typically be the agency that reviewed the construction/storm water pollution prevention plan associated with the project. The “Notice of Termination” shall be mailed to the IDEM at Indiana Department of Environmental Management Storm Water Permits Coordinator 100 North Senate Avenue Mail Code 65-42,Room 1255 Indianapolis, IN 46204-2251 Additional considerations It is not required by 327 IAC 15-5 that the termination is verified prior to submittal, however the SWCD or MS4, as the plan review agency, may elect to field verify project completion prior to the “Notice of Termination” submittal. Several MS4s require (by local ordinance) approval of all terminations prior to submitting the “Notice of Termination” to IDEM. Failure to submit this document to an MS4 that has adopted this provision may be a violation of the local MS4 ordinance. If the agency participates, submit the completed Notice of Termination form to the SWCD or MS4. The request for termination will be reviewed for concurrence and either returned to the project site owner for submittal to IDEM or forwarded to IDEM on behalf of the project site owner. FOR AGENCY USE ONLY (FIELD VERIFICATION OF TERMINATION) The SWCD, an MS4 entity, or the Indiana Department of Environmental Management may inspect the project site to evaluate the adequacy of the remaining storm water quality measures and compliance with the Notice of Termination (NOT) requirements. If the inspecting entity finds that the project site owner has meet the requirements of 327 IAC 15-5-8, the entity may elect to sign off on the project. It is the responsibility of the project site owner to file the NOT with the Indiana Department of Environmental Management. Accepted The site referenced above has been inspected and it has been determined that the request to terminate this project is compliant with the requirements of 327 IAC 15-5. This form must be submitted to the IDEM for final processing. Denied The site referenced above has been inspected and it has been determined that the request to terminate this project is not compliant with the requirements of 327 IAC 15-5. Continue to implement the Storm Water Pollution Prevention Plan and take appropriate measures to minimize the discharge of pollutants.       Signature Printed name Agency Date (month, day , year) American LegalNet, Inc. www.FormsWorkFlow.com