RULE 5 – Notice of Termination (NOT) Storm Water Runoff Associated with Construction Activity NPDES General Permit Rule 327 IAC 15-5 (Rule 5) State Form 51514 (R / 1-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: For questions regarding this form, contact: IDEM – Rule 5 Coordinator 100 North Senate Avenue, Rm 1255 P.O. Box 6015 Indianapolis, IN 46206-6015 Phone: (317) 233-1864 or (800) 451-6027, ext. 31864 (within Indiana) Web Access: http://www.in.gov/idem/water/npdes/permits/wetwthr/storm/rule5.html This Notice of Termination must be signed by an individual meeting the signatory requirements in 327 IAC 15-4-3(g). Please submit the completed Notice of Termination form to the SWCD, DNR-DSC, or other Entity Designated by the Department as the reviewing agency. The request for termination will be reviewed for concurrence and either returned to the Project Site Owner or forwarded to the IDEM. Submission of this Notice of Termination letter constitutes notice to the Commissioner that the project site owner is applying for Termination of Coverage under the National Pollutant Discharge Elimination System (NPDES) General Permit Rule for Storm Water Discharges Associated with Construction Activity. Project Name and Location: Permit Number: ________________ Project Name: ________________________________________________ County: _________________________ Company Name (If Applicable): __________________________________________________________________ Project Site Owner’s Name (An Individual): _________________________________________________________ Address: _____________________________________________________________________________________ City: ______________________ State: _________________ Zip: ________________ Phone: _____________ FAX: ______________ E-Mail Address (If Available): _________________________ This Notice of Termination is Being Submitted for the Following: Select one of the three Options that apply to Permit Termination by checking the appropriate box, complete all information associated with that option, and complete the “Project Site Owner Responsibility Statement”. Option # 1 Certification for Change of Ownership: (Does not Apply to the Sale of Individual lots within the Permitted Acreage; only the Sale of the Entire Project Site as Originally Permitted) 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: _____________________________________________________________________________ City: ______________________ State: _________________ Zip: ________________ Phone: ___________ FAX: ____________ E-Mail Address (If Available): _______________________ B. 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. American LegalNet, Inc. www.FormsWorkflow.com Option # 2 Certification for Termination of Construction Activities: By Signing this Notice of Termination, I Certify the Following: A. All land disturbing activities, including construction on all building lots have been completed and the entire site has been stabilized; B. No future land disturbing activities will occur on this project site; C. all temporary erosion and sediment control measures have been removed; and D. a copy of this notice has been sent to the appropriate SWCD or other designated entity. 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. The remaining, undeveloped acreage does not exceed five (5) acres, with contiguous areas not to exceed one (1) acre. B. 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. C. All public and common improvements, including infrastructure, have been completed and permanently stabilized and have been transferred to the appropriate local entity. D. The remaining acreage does not pose a significant threat to the integrity of the infrastructure, adjacent properties, or water quality. E. All permanent storm water quality measures have been implemented and are operational. Upon Written Notification of the Department the Project Site Owner Certifies that he/she will Notify: A. All current individual lot owners and all subsequent individual 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 remaining individual lot owners do not need to submit a Notice of Intent letter or Notice of Termination letter); and B. the individual lot owners of the requirements to install and maintain appropriate measures to prevent sediment from leaving the individual building lot and 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). Please submit the completed Notice of Termination form to the SWCD, DNR-DSC, or other Entity Designated by the Department as the reviewing agency. The request for termination will be reviewed for concurrence and either returned to the Project Site Owner or forwarded to the IDEM. For Agency Use Only 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 15-5-8. This form will be forwarded to the IDEM for final approval. Upon written notification by the IDEM, the Project Site Owner’s termination for coverage under 327 IAC 15-5 shall be considered approved. 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 15-5-8. Continue to implement the Stormwater Pollution Prevention Plan and take appropriate measures to minimize the discharge of pollutants. ____________________________ Signature ____________________________ Printed Name ________________________________ _________ Agency Date American LegalNet, Inc. www.FormsWorkflow.com