U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY

W ASHINGTON

, DC 20460

N OTICE OF T ERMINATION (NOT) OF C OVERAGE UNDER THE P ESTICIDE G ENERAL P ERMIT

(PGP) FOR D ISCHARGES FROM THE A PPLICATION OF P ESTICIDES Form Approved

OMB No.

XXXX

- XXXX

Electronic Submission Waiver



### I hereby acknowledge my waiver request from the use of EPA’s electronic Notice of Intent system (eNOI) because my use of eNOI will

incur undue burden or expense over my use of this paper Notice of Termination form.

Briefly describe the reason why use of the electronic system causes undue burden or expense.

_______________________________

________________________________ ________________________________ ________________________________ ____________

________________________________ ________________________________ ________________________________ ____________

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A

. Permit Information



### 1. NPDES Permit Tracking Number :

2. Reason for t ermination (check one only):

a. You have ceased all discharges from the application of pesticides for which you obtained permit coverage and you do not expect

to discharge during the remainder of the permit term.

b. Permit coverage has been obtained under an NPDES individual permit or alternative NPDES general permit for all pesticide

discharges requiring NPDES permit coverage either because EPA required you to obtain such coverage or you petitioned EPA

requesting coverage under an alternative NPDES permit.

c

. A new decision

- maker has taken ov er responsibility for the pest control activities

covered under an existing NOI

. Date of transfer: / /



### New Operator Name:

Street :

City: State : Z IP Code:

–



### Telephone:

– – ext



### E

- mail:

B. Operator Information



### 1. Operator Name:

2

. IRS Employer Identification Number (EIN):

3

. Mailing Address: –



### Street:

City: State : ZIP Code:

–



### Telephone:

– – ext



### 4.

. Contact Name :

E

- mail:C

. Certification

I certify under penalty of law that I have met at least one of the reasons for terminating permit coverage listed in Section A above. I understand that by

submitting this Notice of T ermination, I am no longer authorized to discharge pesticides to waters o f the U nited States . This document and all

attachments were prepared under my direction and supervision in accordance with a system designed to ensure that qualified pe rsonnel properly

gather and evaluate the information submitted. The information submitte d 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 or imprison ment. Additionally, I understand

that the submittal o f this Notice of Termination does not release a pesticide operat or from liability for any violations of the Clean Water Act.



### Printed Name:

Title:

E

- Mail:

Sig nature/Responsible Official: Date: / /

NO T Preparer (Complete if NO T was prepared by someone other than the certifier)



### Preparer

Name :

Organization:

Phone:

– – 

### E xt Date: / /



### E

- Mail: