DHEC 2610
(06/2013)
SOUTH CAROLINA DEPARTMENT OF
HEALTH AND ENVIRONMENTAL CONTROL
Page
3
Notice of Termination (NOT) of Coverage
Application Instructions
This form is for the use on all projects where an NPDES permit has been obtained under the South Carolina Construction
General Permit. The form must be completed by the permittee.
Completing the Application:
You must type or print legibly. You must include the original, signed notification form and only the first two pages of this
document.
I.
Permit Information
A. Project/ Site Name: The Project/Site Name should match the name on the NPDES approval letter issued by SC
DHEC.
B. NPDES Coverage Number and State File Number: Enter the existing NPDES Stormwater General Permit
tracking number and State file number listed on the approval letter.
C. MS4 Operator: Provide the MS4 entity governing the project area. If none exists, list N/A.
D. MS4 Certification Statement: Provide the certification from the MS4 that the project is complete and meets the
requirements for termination of coverage. If no MS4 exists, select N/A.
E. Reason for Termination: Indicate the reason for submitting this Notice of Termination by checking the
appropriate box. Select only one.
II.
Site Information
A. Site Location: Provide the street address for the physical location of the site. If the project or site lacks a street
address, indicate the general location of the site (e.g., Intersection of State Highways 61 and 34).
B. Property Owner: If the Project Operator does not own the project site, then list the official or legal name of the current
Property Owner of the site.
III.
Permittee Information
A. Project Owner/ Operator: Provide the official or legal name of the Project Owner/Operator (PO/O). The
Company EIN is the Employer Identification Number as established by the U.S. Internal Revenue Service; the EIN
is commonly referred to as the taxpayer ID. If the PO/O is not a company, then do not list a Company EIN. Please
provide the phone number, completed mailing address, and email address.
B. Permit Contact: If the Project Owner/ Operator is a company, then a Permit Contact person must be listed under
section B. This can be someone other than the person that has signatory authority for the company. Please
provide all requested information including email addresses.
IV.
Permittee Signature and Certification
Federal statutes provide for severe penalties for submitting false information on this application form. Federal
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, or (ii) the manager of one or more manufacturing, production, or operating
facilities employing more than 250 persons or having gross annual sales or expenditures exceeding $25 million (in
second-quarter 1980), if 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 municipality, State, Federal, or other public facility: by either a principal executive officer or ranking elective
official.
V.
SWPPP Preparer/Engineer Signature and Certification
If the project disturbs 2 or more acres, the preparer of the C-SWPPP or a person with the registration equivalent to
that of the preparer of the C-SWPPP must certify that, to the best of his or her knowledge and belief, all work was
conducted and completed in accordance with the approved OS-SWPPP and the 2012 SC Construction General
Permit.
Where to File:
Projects in the 8 coastal counties: Projects located in all other counties:
S.C. DHEC - Coastal Stormwater Permitting Section
1362 McMillan Avenue, Suite 3400
Charleston, SC 29405
S.C.DHEC—Stormwater Permitting Section
2600 Bull Street
Columbia, SC 29201-1708