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HomeMy WebLinkAboutIowa Department of Natural Resources-12/10/2012NOTICE OF DISCONTINIJATION OF A STORM WATER DISCHARGE COVERED UNDER IOWA NPDES GENERAL PERMIT NO. 2 FOR CONSTRUCTION ACTIVITIES Name of the owner or facility to which the storm water discharge general permit coverage was issued. �1Ver Pf e tS,CifCC, er I'Ia7L1L County: Nark-- iircuin2I4--- List the complete permit authorization number for the discharge. This number is provided on the bottom of the authorization sheet. IA - D 1 EL, List the date the construction site reached final stabilization as defined on the back of this form. The following certification must be signed in accordance with the signatory requirements of the general permit (see back side). I certify under penalty of law that disturbed soils at the identified facility have been finally stabilized and temporary erosion and sediment control measures have been removed or will be removed at an appropriate time. I understand that by submitting this Notice of Discontinuation, I am no longer authorized to discharge storm water associated with industrial activity for construction activities by Iowa Department of Natural Resources NPDES General Permit No. 2 and that discharging pollutants from storm water associated with industrial activity to waters of the United States is unlawful under the Clean Water Act where the discharge is not authorized by an NPDES permit. I further 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 known violations. Lift Name (print) Signature Return to: (1\r scr Title C'nlig.-tt I b Pm-- Date Storm Water Coordinator Department of Natural Resources 502 E. 9th Street Des Moines, IA 50319-0034 542-8115 (over) Final Stabilization means that all soil disturbing activities at the site have been completed and that a uniform perennial vegetative cover for the area has been established or equivalent stabilization measures have been employed. All building mist be completed before the project is considered finally stabilized. SIGNATORY REQUIREMENTS All Notices of Intent, storm water pollution prevention plans, reports, certifications or information either submitted to the Department or the operator of a large or medium municipal separate storm sewer system, or that this permit requires be maintained by the permittee, shall be signed in accordance with rule 567-64.3(8) of the Iowa Administrative Code as follows: 64.3(8) Identity of signatories of operation permit applications. The person who signs the application for an operation permit shall be: a. Corporations. In the case of corporations, a principal executive officer of at least the level of vice- president. b. Partnerships. In the case of a partnership, a general partner. c. Sole proprietorships. In the case of a sole proprietorship, the proprietor. d. Public facilities. In the case of a municipal, state, or other public facility, by either the principal executive officer, or the ranking elected official. e. Storm water discharge associated with construction activity. In the case of a storm water discharge associated with industrial activity from construction as identified in 40 CFR 122.26(b)(14)(x), either the owner of the site or the general contractor. NOTICE OF DISCONTINUATION OF A STORM WATER. DISCHARGE COVERED UNDER IOWA NPDES GENERAL PERMIT NO. 2 FOR CONSTRUCTION ACTIVITIES Name of the owner or facility to which the storm water discharge general permit coverage was issued.r - OGM—Ie CAICreSJ ff'' Ir 1'1vd icr kAhitl p .51-ccftUr County: 13L'2 rk- !4z t c k_ -- List the complete permit authorization number for the discharge. This number is provided on the bottom of the authorization sheet. IA- pC/gyg Cqi /5 - List the date the construction site reached final stabilization as defined on the back of this form. f 4�ng ac, a0)2 The following certification must be signed in accordance with the signatory requirements of the general permit (see back side). I certify under penalty of law that disturbed soils at the identified facility have been finally stabilized and temporary erosion and sediment control measures have been removed or will be removed at an appropriate time. I understand that by submitting this Notice of Discontinuation, I am no longer authorized to discharge storm water associated with industrial activity for construction activities by Iowa Department of Natural Resources NPDES General Permit No. 2 and that discharging pollutants from storm water associated with industrial activity to waters of the United States is unlawful under the Clean Water Act where the discharge is not authorized by an NPDES permit. I further 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 known violations. Gr 5- G -{`t 6LYk Name (print) bell( ! n Mayor I Title /12k1i4" � Signature 011 U , iV fr2 Date Return to: Storm Water Coordinator Department of Natural Resources 502.E. 9th Street Des Moines, IA 50319-0034 542-8115 (over) Final Stabilization means that all soil disturbing activities at the site have been completed and that a uniform perennial vegetative cover for the area has been established or equivalent stabilization measures have been employed. All building must be completed before the project is considered finally stabilized. SIGNATORY REQUIREMENTS All Notices of Intent, storm water pollution prevention plans, reports, certifications or information either submitted to the Department or the operator of a Large or medium municipal separate storm sewer system, or that this permit requires be maintained by the permittee, shall be signed in accordance with rule 567--64.3(8) of the Iowa Administrative Code as follows: 64.3(8) Identity of signatories of operation permit applications. The person who signs the application for an operation permit shall be - a. Corporations. In the case of corporations, a principal executive officer of at least the level of vice- president. b. Partnerships. In the case of a partnership, a general partner. c. Sole proprietorships. In the case of a sole proprietorship, the proprietor. d. Public facilities. In the case of a municipal, state, or other public facility, by either the principal executive officer, or the ranking elected official. e. Storm water discharge associated with construction activity. In the case of a storm water discharge associated with industrial activity from construction as identified in 40 CFR 122.26(b)(14)(x), either the owner of the site or the general contractor.