Alaska Pollutant Discharge Elimination System (APDES)
Notice of Termination of Wastewater Discharge

Submit this Notice of Termination (NOT) to:

Alaska Department of Environmental Conservation Wastewater Discharge Authorization Program 555 Cordova Street Anchorage, Alaska 99501 or via email: DEC.Water.WQPermit@alaska.gov

Submission of this document constitutes notice that the party identified in Section 2 intends to discontinue coverage for the permit as indicated in Section 4 of this form. Please provide all information below and attach supplemental information sheets as appropriate.

1. Permit Information
Permit No:	Enter Text

2. Responsible Party Information (Owner/Operator or Person responsible for overall management of the project, as it appears on the application or Notice of Intent)
Operator Name:	Organization:	Title:
Enter Text	Enter Text	Enter Text
Phone:	Fax (optional):	Email:
Enter Text	Enter Text	Enter Text
Mailing Address:
Street (PO Box):
Enter Text
City:	State:	Zip:
Enter Text	Enter Text	Enter Text

3. Facility or Project/Site Information (As it appears on the application or Notice of Intent. For mobile operations, submit the final location at which operations have ceased.)
Facility/Project Name:
Enter Text
Phone:	Fax (optional):	Email:
Enter Text	Enter Text	Enter Text
Location Address:	Street (PO Box):	Borough or similar government subdivision
Enter Text	Enter Text
City:	State:	Zip:
Enter Text	Alaska	Enter Text
Latitude (decimal degree, 5 places)	Longitude (decimal degree, 5 places)	Determined By:
Enter Text	Enter Text	☐ GPS ☐ USGS Topo Map ☐ Internet Map Service

4. Reason for Termination (Check the appropriate box indicating the reason for terminating coverage.)
☐	Operations have ceased at the facility and there are no longer discharges associated with the conditions of the referenced permit.
☐	Coverage under an individual permit or alternative APDES general permit has been obtained. If checked, please list the permit authorization number used to cover this discharge: Enter Text
☐	Other (Specify):	Enter Text

5. Permit Reporting Requirements
☐	All reporting requirements as required by the permit have been submitted to DEC.

6. Certification
An Alaska Pollutant Discharge Elimination System (APDES) permit application or report must be signed by an individual with the appropriate authority per 18 AAC 83.385. For additional information, please refer to 18 AAC 83.385 at the following link: http://www.legis.state.ak.us/basis/aac.asp#18.83.385. Corporate Executive Officer 18 AAC 83.385 (a)(1)(A) For a corporation, a 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. Corporate Operations Manager 18 AAC 83.385 (a)(1)(B) For a corporation, the manager of one or more manufacturing, production, or operating facilities, if the manager is authorized to make management decisions that govern the operation of the regulated facility, 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 statutes 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 authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures. Sole Proprietor or General Partner 18 AAC 83.385 (a)(2) For a partnership or sole proprietorship, the general partner or the proprietor respectively. Public Agency, Chief Executive Officer 18 AAC 83.385 (a)(3)(A) For a municipality, state, or other public agency, the chief executive officer of the agency. Public Agency, Senior Executive Officer 18 AAC 83.385 (a)(3)(B) For a municipality, state, or other public agency, a senior executive officer having responsibility for the overall operations of a principal geographic unit or division of the agency. Any report required by an APDES permit, and a submittal with any other information requested by the department, must be signed by a person described in above, or by a duly authorized representative of that person. *For Delegated Authority: the delegation must be made in writing and submitted to the DEC. Your signature will not be approved until DEC receives the written delegation. An Example of written authorization delegating authority can be found on the Division of Water website: http://dec.alaska.gov/Water/OASysHelp/attachments/Delegation_Authorization_Form.pdf Operations Manager (Delegated Authority)* 18 AAC 83.385 (b)(2)(A) For a duly authorized representative, an individual or a position having responsibility for the overall operation of the regulated facility or activity, including the position of plant manager, operator of a well or a well field, superintendent or position of equivalent responsibility. Environmental Manager (Delegated Authority)* 18 AAC 83.385 (b)(2)(B) For a duly authorized representative, an individual or position having overall responsibility for environmental matters for the company.
I 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. Per 18 AAC 83.130(k), I certify there are no current or pending state or federal enforcement actions, including citizen suits brought under state or federal law. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Organization:	Name:	Title:
Enter Text	Enter Text	Enter Text
☐ Check if same as Operator Information in Section 2.	Phone:	Fax (optional):	Email:
Enter Text	Enter Text	Enter Text
Street (PO Box):
Enter Text
City:	State:	Zip:
Enter Text	Enter Text	Enter Text
Enter Date Signature/Responsible Official Date

7. NOT Preparer (Complete if NOT was prepared by someone other than the certifier.)
Organization:	Name:	Title:
Enter Text	Enter Text	Enter Text
Phone:	Fax (optional):	Email:
Enter Text	Enter Text	Enter Text
Mailing Address: ☐ Check if same as Operator Information in Section 2	Street (PO Box):
Enter Text
City:	State:	Zip:
Enter Text	Enter Text	Enter Text