UPDES Storm Water Notice of Termination Inspection Form

Background Information

Site Name

UPDES Permit Number

Site Address

Local Jurisdiction or County

Permit Effective Date

Permit Expiration Date

Total Project Area

Total Disturbed Area

Project Type

Subdivision Commercial Industrial Linear (Road/Pipe/Power) Land Disturbance

Operator Contact Information

Operator Name

Operator Phone Number

Operator E-mail

Onsite Facility Contact Name

Onsite Facility Contact Phone Number

Onsite Facility Contact E-mail

Important Contact 1 Name

Important Contact 1 Phone Number

Important Contact 1 E-mail

Important Contact 2 Name

Important Contact 2 Phone Number

Important Contact 2 E-mail

Notice of Termination Inspection

Site Name

Date of Evaluation

Site Address

Inspected By

Title or Organization

1. Has the site been properly stabilized according to permit requirements?

Yes No

Comments for Question 1

2. Have all temporary BMPs been removed?

Yes No

Comments for Question 2

3. Have post-construction (permanent storm water system) elements been constructed and inspected in accordance with approved project drawings?

Yes No

Comments for Question 3

4. Is the site acceptably clean?

Yes No

Comments for Question 4

Certification Statement

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 gathered and evaluated 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.

Inspector

Print Name

Title

Signature

Date

Operator

Print Name

Title

Signature

Date

UPDES Storm Water Notice of Termination Inspection Form

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