Document ID: EPA-HQ-OW-2020-0005-0053
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2021-01-15T05:00Z

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. 
2040-0004 
Approval to Use Paper NOT Form (Electronic Submission Waiver)
Has the EPA Regional Office granted you a waiver from electronic reporting*?	 YES	 NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:
Waiver granted:
  The Decision-maker is physically located in a geographical area (i.e., ZIP code or census tract) that is identified as under-served for broadband Internet access in the most recent report from the Federal Communications Commission.
  The Decision-maker has limitations regarding available computer access or computer capability.
Name of EPA staff person  who granted the waiver:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

Date approval obtained: 
                                       
                                       
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*Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper NOT form. If you have not obtained a waiver, you must file this form electronically using EPA's NPDES eReporting Tool (NeT) at https://www.epa.gov/npdes/pesticide-permitting. 
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. You have obtained permit coverage under an NPDES individual permit or alternative NPDES general permit for all pesticide discharges requiring NPDES permit coverage.
    c. A new Operator has taken over decision-making responsibility for the pest control activities covered under an existing NOI. Provide the transfer date and the new Operator information.
                                                              Date of transfer:
                                       
                                       
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New Operator Name:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

Street:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

City:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

State:
                                       
                                       

ZIP Code:
                                       
                                       
                                       
                                       
                                       
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Telephone: 
                                       
                                       
                                       
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                                     Ext.
                                       
                                       
                                       
                                       

E-mail:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

B. Operator Information
1. Operator Name:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

2. Mailing Address:

Street:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

City:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

State:
                                       
                                       

ZIP Code:
                                       
                                       
                                       
                                       
                                       
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Telephone: 
                                       
                                       
                                       
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                                     Ext.
                                       
                                       
                                       
                                       

3. 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. On the basis of 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 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:
                                       
                                       
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NOT Preparer (Complete if NOT was prepared by someone other than the certifier)
Preparer Name: 
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

Organization:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

Phone:
                                       
                                       
                                       
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                                     Ext.
                                       
                                       
                                       
                                       

                                                                          Date:
                                       
                                       
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E-Mail:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

Instructions for Completing the Notice of Termination (NOT) of Coverage under the Pesticide General Permit (PGP) for
                 Discharges from the Application of Pesticides

Who Must File an NOT with EPA?
Any Operator required to submit a Notice of Intent (NOI) is required to submit a Notice of Termination (NOT) to end coverage under this permit. However, if EPA notifies the Operator to apply for an NPDES individual permit or alternative general permit, coverage under this permit terminates automatically. Dischargers automatically covered under this permit as identified in Part 1.2.3 of the permit are likewise automatically terminated upon permanent cessation of discharge consistent with any of the criteria identified in Part 1.2.5.3 of the permit. As required in the permit, only certain Operators who are also Decision-makers must submit NOIs. Note: NOIs submitted under the 2016 PGP are automatically terminated on October 31, 2021. Decision-maker who are required to submit an NOI must submit a new NOI to obtain coverage under the 2021 PGP.
If you have questions about whether you need to file an NOT or questions about completing the form, see https://www.epa.gov/npdes/pesticide-permitting or contact the NOI Center toll free at 866-352-7755.
When to File the NOT?
Approval to Use Paper NOT Form: Note that you are not authorized to use this paper NOT form unless the EPA Regional Office has approved its use. Where you have obtained approval to use this form, indicate the waiver that you have been granted, the name of the EPA staff person who granted the waiver, and the date that approval was provided. 
Operators must file the NOT form within 30 days after one or more of the conditions in Part 1.2.5.2 of the permit have been met.
Where to File the NOT?
Consistent with Part 1.2.5.1 of the permit, the Operator must submit the NOT using EPA's NPDES eReporting Tool (NeT) available on EPA's website (https://www.epa.gov/npdes/pesticide-permitting) unless the Operator is granted a waiver from the requirement to use NeT for submission of the NOT. See Part 8 of the PGP for EPA Regional contacts. The Electronic Submission Waiver is at the top of this NOT form. 
Filing electronically is the fastest way to terminate permit coverage and help ensure that your NOT is complete.
If you are granted a waiver from using NeT; you must send the NOT form to one of the addresses listed below.
  Via United States Mail:
  United States Environmental Protection Agency
Office of Water, Water Permits Division
Mail Code 4203M, ATTN: NPDES Pesticides
1200 Pennsylvania Avenue, NW
Washington, DC 20460
  Via overnight/express delivery:
  United States Environmental Protection Agency
Office of Water, Water Permits Division
EPA East Building - Room 7420, ATTN: NPDES Pesticides
1201 Constitution Avenue, NW
Washington, DC 20004
Phone: 202-564-9545
If you file a paper NOT, submit the original form with a signature in ink. Do not send copies. Also, faxed copies will not be accepted.
Completing the NOT Form
To complete this form, type or print in uppercase letters in the appropriate areas only. Make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the address above. You can also use this paper form as a checklist for the information you will need when filing an NOT electronically via EPA's NPDES eReporting Tool (NeT).
Section A. Permit Information
1.	Enter the existing NPDES Permit Tracking Number assigned by NeT or EPA's Pesticides Processing Center. You can find the tracking number assigned to your previous NOI using EPA's NeT. 
2.	Select the appropriate box to indicate why you are submitting an NOT to end permit coverage. Select one of the three termination options: 
   a. 	Select this box if 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. 	Select this box if you have obtained NPDES individual permit coverage or alternative NPDES permit coverage.
   c. 	Select this box if a new Operator has taken over decision-making responsibility of pest control activities covered under an existing NOI and you are no longer the Operator. Provide the date of transfer and the name and contact information of the new Operator.
Section B. Operator Information
1.	Provide the full legal name of the person, firm, public organization, or other entity that is the Operator who is the Decision-maker for the pesticide application described in this application.
2.	Provide the Operator's mailing address and telephone number. Correspondence will be sent to this address.
3.	Provide a contact person's full legal name and e-mail address. This person will be contacted regarding any NOT communication. 
Section C. Certification
Carefully read the certification statement. By completing and submitting the NOT, the Operator certifies that the Operator is no longer authorized to discharge pesticides to waters of the United States. Provide the printed full legal name, title and email address of the certifier. Sign and date the form. (CAUTION: An unsigned or undated NOT form will prevent the termination of permit coverage.) 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 for the corporation, or
  (ii) the manager of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make management decisions that govern the operation of the regulated activity including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where 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 municipal, state, federal, or other public facility: by either a principal executive or ranking elected official.
If the NOT was prepared by someone other than the certifier (for example, if the NOT was prepared by the PDMP contact or a consultant for the certifier's signature), include the name, organization, phone number and e-mail address of the NOT preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is estimated to average 0.5 hours or 30 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed NOT form to that address.