VIDPNR Permit No: VIR050000 - Notice of Termination (NOT) Form Page 1 of 3 USVI Department of Planning and Natural Resources NOTICE OF TERMINATION (NOT) FORM for Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the 2017 TPDES Multi-Sector General Permit (VI MSGP) No. VIR050000 Submission of this Notice of Termination (NOT) constitutes notice that the party identified in Section B of this form is no longer authorized to discharge stormwater associated with industrial activity under VIDPNR’s TPDES Stormwater Multi-Sector General Permit for the facility identified in Section C of this form. All necessary information must be included on this form. Refer to the instructions at the end of this form. A. Permit Tracking Number 1. TPDES Permit Tracking No. 2. Reason for Termination (check one box only): a. You transferred operational control to another operator. b. You no longer have a stormwater discharge associated with industrial activity subject to regulation under the TPDES program, and you have already implemented necessary sediment and erosion controls as required by Part 2.1.2.5. c. You are a Sector G, H, or J facility and you have met the applicable termination requirements. d. You obtained coverage under an alternative TPDES permit. B. Facility Operator Information 1. OPERATOR Information: Operator Name _______________________________________________________________________________ Mailing Address _______________________________________________________________________ _______________________________________________________________________ Phone (_____)_______________ Fax: (_____)_______________ Email ____________________________________________________________________________________ 2. OPERATOR Point of Contact Information: First, Middle Initial, Last Name: ___________________________________________________________________ Title: _______________________________________________________ Mailing Address: _______________________________________________________________________ _______________________________________________________________________ Phone : (_____)_______________ Fax: (_____)_______________ Email: ____________________________________________________________________________________ C. Facility Information VIDPNR Permit No: VIR050000 - Notice of Termination (NOT) Form Page 2 of 3 1. Facility Name _____________________________________________________________________________ 2. Facility Physical Address _____________________________________________________________________________ _____________________________________________________________________________ D. Certification 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 gathered and evaluated 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. Name: ________________________________________________________________ Title: ________________________________________________________________ Signature: ________________________________________________________________ Date: ______________ Email: __________________________________________________ VIDPNR Permit No: VIR050000 - Notice of Termination (NOT) Form Page 3 of 3 Instructions for Completing the Notice Of Termination (NOT) For Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the VIDPNR TPDES Multi-Sector General Permit ( VI MSGP) Who May File A Notice of Termination (NOT) Form. Permittees currently covered by VIDPNR’s TPDES Stormwater Multi-Sector General Permit may submit a Notice of Termination (NOT) form. You must submit an NOT within 30 days after one or more of the following conditions have been met:  a new owner or operator has assumed responsibility for the facility; or  you have ceased operations at the facility and there are not or no longer will be discharges of stormwater associated with industrial activity from the facility, and you have already implemented necessary sediment and erosion controls as required by Part 2.1.2.5;  you are a Sector G, H, or J facility and you have met the applicable termination requirements; or  you have obtained coverage under an individual or alternative general permit for all discharges required to be covered by a TPDES permit. See the VI MSGP Part 1.4 for more information. Where To File NOI Form. NOIs must be submitted to VI DPNR at the office in the district where the facility operates, as follows: St. Croix Department of Planning and Natural Resources Division of Environmental Protection Water Pollution Control Program 45 Mars Hill Frederiksted, VI 00841 St. Thomas Department of Planning and Natural Resources Division of Environmental Protection Water Pollution Control Program Charles W. Turnbull Regional Library 12 BA-2 Frydendahl, Rte 384, Anna's Retreat St. Thomas, VI 00801 Please submit the original with a signature in ink – Do Not Send Copies. Also, faxed copies will not be accepted. Completing the Form Please make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the address above. Please submit original document with signature in ink - do not send a photocopied signature. Fees There are no fees for termination of a permit, but terminating a permit may decrease the annual discharge fee. Section A: Permit Number. 1. Enter the NPDES tracking number assigned by VIDPNRs Srmwater Notice Processing Center to the facility. 2. Indicate your reason for submitting this Notice of Termination by checking the appropriate box (see MSGP Part 1.4 for more information). Section B: Facility Operator Information 1. Provide the legal name of the person, firm, public organization or any other public entity that operates the facility described in this application. An operator of a facility is a legal entity that controls the operation of the facility. 2. Provide the operator’s mailing address here. Correspondence will be sent to this address. 3. Provide the telephone number of the line at the facility. 4. Provide a fax number (if one exists). 5. Provide an email address available to receive electronic correspondence. Section C: Facility Information 1. Provide the facility’s official or legal name. 2. Provide the facility’s physical address here. Do not use a P.O. Box. 3. Provide the telephone number of the line at the facility. 4. Provide a fax number (if one exists). Section H: Certification Certification statement and signature (see Section 11 of Appendix B of the MSGP for more information). Enter certifier’s printed name, title and email address. Sign and date the form. Territorial statutes provide for severe penalties for submitting false information on this application form. Territorial regulations require this application to be signed as follows: For a corporation: by a responsible corporate officer, which means: (i) president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision making functions for the corporation, or (ii) the manager of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures; For a partnership or sole proprietorship: by a general partner or the proprietor; or For a municipal, State, Federal, or other public facility: by either a principal executive or ranking elected official. ADDENDUM TO NOTICE OF TERMINATION EFFECTIVE DATE OF TERMINATION FOR PURPOSES OF DETERMINING 2020 ANNUAL DISCHARGE FEE You are not required to file this Addendum, but doing so may decrease or eliminate your 2020 annual discharge fee. Submit this to DPNR with your Notice of Termination no later than October 1, 2020. TPDES Permit Tracking No. __________________ I request that my permit coverage be terminated effective [insert date] _____________ because, on or before that date (check one only): ☐ I transferred operation control to another operator. ☐ I no longer had a stormwater discharge associated with industrial activity subject to regulation under the TPDES program, and I had already implemented necessary sediment and erosion controls as required by Part 2.1.2.5. ☐ I am a Sector G, H, or J facility and I had met the applicable termination requirements. ☐ I obtained coverage under an alternative TPDES permit. I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated 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. Name: ________________________________________________________________ Title: ________________________________________________________________ Signature: ________________________________________________________________ Date: _____________ Email: __________________________________________________ EXPLANATION: Starting in 2020, permittees are required to pay an annual discharge fee each year in which they are covered by a TPDES permit. When a permittee terminates permit coverage by filing a Notice of Termination, that year’s annual discharge fee will be prorated based on the date DPNR receives the Notice of Termination. For example, if a permittee no longer had stormwater discharge associated with industrial activity and implemented necessary sediment and erosion controls as of January 31, and filed a Notice of Termination on July 1, they would owe a 6-month discharge fee under our normal rules. Because permittees did not know that late filing of a Notice of Termination would affect their fees, DPNR is giving permittees a one-time opportunity to request that permit coverage be terminated on the date they complete the activities necessary for termination. Based on accurate information provided to DPNR in this Addendum, 2020 annual discharge fees for terminated permits will be prorated based on when the permit should have been terminated, not when DPNR receives the Notice of Termination.