City of Dyersburg
Storm Water Management Department
NOTICE OF TERMINATION
The purpose of this form is to notify the City of Dyersburg Storm Water Management Department that you, as a permitted operator of
storm water discharges from a construction activity, no longer have responsibilities related to erosion and sediment controls at the
construction site. Type or print clearly, using ink and not markers or pencil.
Land Disturbance Permit Number
Name of construction project (site)
Street address (or description of location)
Legal name of construction site operator
Mailing address
Telephone number and/or e-mail address
( )
Have the storm water dischar
es with construction activit
been eliminated? YES NO
If “YES” to the above
uestion,
rovide a date at which the construction site was finall
stabilized.
Construction activities at the site continue, but my responsibilities with respect to the
construction activities have ceased. YES NO
If “YES” to the above question, provide the name, mailing address and telephone number of any new operators (for instance, an operator
who has taken over your responsibilities) involved with soil disturbance at the construction site.
Certification and si
nature
President, Vice President, Land Owner or e
uivalent
I certify under penalty of law that either: (a) all storm water discharges associated with construction activity from the portion of the identified
facility where I was an operator have ceased or have been eliminated or (b) I am no longer an operator at the construction site. I
understand that by submitting this Notice of Termination, I am no longer authorized to discharge storm water associated with construction
activity under this Land Disturbance Permit, and that discharging pollutants in storm water associated with construction activity to the
conveyances of the City of Dyersburg is unlawful under the City of Dyersburg Storm Water Ordinance where the discharge is not
authorized by a Land Disturbance Permit. I also understand that the submittal of this notice of termination does not release an operator
from liability for any violations of this permit, the City of Dyersburg Storm Water Ordinance or the Clean Water Act.
For the purpose of certification, elimination of storm water discharges associated with construction activity means that all disturbed soils at
the portion of the construction site where the operator had control have been finally stabilized and temporary erosion and sediment control
measures have been removed or will be removed at the appropriate time to insure final stabilization is maintained, or that all storm water
discharges associated with construction activities from the identified site that are authorized by a Land Disturbance Permit have otherwise
been eliminated from the portion of the construction site where the operator had control.
Print or type name Signature Date
Permittees who are presently covered under the City of Dyersburg Land Disturbance Permit to discharge storm water associated with
construction activity must submit a Notice of Termination after completion of their construction activities and final stabilization of their
portion of the site, or within 30 days after another operator has taken over all of their responsibilities at the site. A permittee cannot submit
a NOT without final stabilization unless another party has agreed to assume responsibility for the final stabilization of the site. A completed
NOT form should be submitted to:
City of Dyersburg
Storm Water Management Department
P.O. Box 1358
Dyersburg, TN 38025-1358
