UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, DC 20460

NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER THE PESTICIDE GENERAL PERMIT

(PGP) FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES

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 termination (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 over responsibility for the pest control activities

covered under an existing NOI.

Date of transfer: / /

New Operator Name:

Street:

City: State: ZIP 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 Termination, I am no longer authorized to discharge pesticides to waters of the United States. This document and all 

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

gather and evaluate the information submitted. 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 or imprisonment. Additionally, I understand 

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

Printed Name:

Title:

E-Mail:

Signature/Responsible Official: Date: / /

NOT Preparer (Complete if NOT was prepared by someone other than the certifier)

Preparer 

Name: 

Organization:

Phone: – – Ext Date: / /

E-Mail: