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Notice of Termination (NOT) of Coverage Under an (Town of Fort Mill)

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BROWSE TOWN OF FORT MILL (SC) FORMS

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Notice of Termination (NOT) of Coverage
Under an NPDES General Permit for Stormwater Discharges
Associated with Construction Activity
(Authorization to discharge terminates at midnight of the day the NOT is signed)
If an NOT has been submitted and the construction site does not meet the criteria for termination, then the
construction site remains subject to the provisions of the 2012 Construction General Permit.
I. Permit Information
A. Project/ Site Name: ___________________________________________________________________________
B. NPDES Coverage Number: SCR10 __ __ __ __ State File Number: __ __ - __ __ - __ __ - __ __
C. MS4 Operator (N/A if none): ____________________________________________________________________
D. Is MS4 certification statement attached? Yes No N/A
E. Reason for Termination
(select only one):
Final stabilization has been achieved on all portions of the site.
Another operator has assumed control according to §122.41(l)(3) of SC Regulation 61-9, over all areas of the
construction site that have not reached final stabilization.
New Owner/ Operator (Company or person): ________________________________________________
Mailing Address: _____________________________________________________________________
Coverage under an individual or alternative general NPDES permit has been obtained:
New NPDES: SCR10 __ __ __ __ State File Number: __ __ - __ __ - __ __ - __ __
For residential developments only, final stabilization has been achieved on all portions of the site, except for
areas where a Secondary Permittee has obtained permit coverage for the individual lot(s) in accordance with
Section 2.2.2 of the Construction General Permit
For residential lots only, either (1) final stabilization has been achieved on all portions of a residential lot(s), or
(2) temporary stabilization including perimeter controls for a residential lot(s) have been achieved prior to
occupation of the home by the homeowner and that the homeowner has been informed, by the
Primary/Secondary Permittee, about the need for, and benefits of, final stabilization.
For construction activities on land used for agricultural purposes (e.g., pipelines across crop or range land,
staging areas for highway construction, etc.), either (1) final stabilization has been accomplished by returning
the disturbed land to its preconstruction agricultural use, or (2) for any areas disturbed that were not previously
used for agricultural activities and areas which are not being returned to their preconstruction agricultural use
have achieved final stabilization, as defined by this permit.
Land disturbance activities were never initiated on the construction site and the construction site remains
permanently stabilized.
II. Site Information
A. Site Location: ________________________________________________________________________________
Address:____________________________________________________________________________________
B. Property Owner (If not the Permittee): _____________________________________________________________
Mailing Address: _____________________________________________________________________________
Phone: (Day) ____________________ Email Address: _______________________________________________
DHEC 2610
(06/2013)
SOUTH CAROLINA DEPARTMENT OF
HEALTH AND ENVIRONMENTAL CONTROL
Page 1
Print Form
DHEC 2610
(06/2013)
SOUTH CAROLINA DEPARTMENT OF
HEALTH AND ENVIRONMENTAL CONTROL
Page 2
III. Permittee Information
A. Project Owner/ Operator (Company or person):______________________________________________________
Company EIN: __ __ - __ __ __ __ __ __ __ Phone: _________________________________________________
Mailing Address: ________________________________________ _____________________________________
City: _______________________________State: ________ Zip: _______________________________________
Email address: _______________________________________________________________________________
B. Permit Contact (If Owner Is a Company):___________________________________________________________
Phone: _____________________ Email address: ___________________________________________________
Mailing Address: ________________________________________ _____________________________________
City: _______________________________State: ________ Zip: _______________________________________
IV. Permittee Signature and Certification
“In the case that the site associated with this project is located within an Urbanized Area (UA) or MS4, I certify that
the respective UA or MS4 has been informed about the scope of all land-disturbing construction and associated
activity pertaining to this site, and that all additional requirements mandated by the UA or MS4 has been
addressed.”
“I also 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 Permittee Title/Position
___________________________________________ _________________________
Signature of Permittee Date
V. SWPPP Preparer/Engineer Signature and Certification
“I, the preparer of the C-SWPPP or other person with a registration equivalent to that of the preparer of the C-
SWPPP, certify that, based on the inspections performed in accordance with section 4.2 of the 2012 Construction
General Permit (CGP), all work was conducted and completed in accordance with the approved SWPPP and the
CGP, and that all deficiencies, as noted by the inspections performed, have been corrected.”
________________________________________________ ________________________
Printed Name of C-SWPPP Preparer S.C. Registration #
________________________________________________ _______________________
Signature of C-SWPPP Preparer Date
PLEASE DO NOT INCLUDE THE APPLICATION INSTRUCTIONS WITH YOUR SUBMITTAL
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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
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Notice of Termination (NOT) of Coverage Under an (Town of Fort Mill)

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Completed 9 February 2021

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