Laserfiche WebLink
Groundwater VOC and Fuel General Permit ORDER NO.R2-2012-0012 <br /> NPDES NO.CAG912002 <br /> ATTACHMENT C—NOTICE OF TERMINATION <br /> Complete and Submit to Request Termination of Coverage Under Requirements of <br /> General Waste Discharge Requirements for Discharge or Reuse of Extracted and Treated <br /> Groundwater resulting from the Cleanup of Groundwater Polluted by Volatile Organic <br /> Compounds (VOC), Fuel Leaks,and Other Related Wastes <br /> NPDES Permit No. CAG912002 (VOC and Fuel General Permit) <br /> For the Groundwater Treatment Facility located at: <br /> Facility Street Address, City,Zip Code CIWQS Place Identification Number <br /> A PDF electronic copy of this form shall be uploaded on GeoTracker and a confirmation email shall be <br /> sent to the responsible staff inember at this office, currently Lourdes Gonzales, at <br /> lgonzales@waterboards.ca.gov. <br /> Table C-1. Mark onl one as a licable <br /> 1 Tem ora roundwater dewaterin ro'ect,e. .,durin a construction ro'ect,has been com leted. <br /> 2 Groundwater cleanu work has been com leted. <br /> 3 Method of oundwater cleanu has been chan ed with no need to dischar e treated roundwater. <br /> Extract and treat method of groundwater cleanup will be stopped for a while and only monitoring of <br /> 4 groundwater will occur at this site. Please attach documentation that the agency overseeing cleanup <br /> has no ob'ection to cessation of oundwater extraction and treatment. <br /> 5 Other reason.Please specify below(e.g.,discharge to POTW has been granted): <br /> Table C-2.A enc A roval a licable if Table C-1 row 2, 3, or 4 marked <br /> Name,address,email,and phone number of the Have you provided a copy of this termination <br /> agency and agency staff overseeing the cleanup notice to this staff?(Yes/No.If No,please explain <br /> work the reason <br /> 1 <br /> I, the Discharger, certify under penalty of law that this notice is prepared under my direction or <br /> supervision and lasdfmal date of this discharge was . I am aware that <br /> discharging without a discharge authorization is in violation of California Water Code. <br /> Name(print) Signature and Date <br /> Title/Organization(Discharger's Organization) Address, email, and phone number <br /> Note:The Regional Water Board may modify this form at any time to reflect new requirements and other needed improvements. <br /> Attachment C—Notice of Termination C-1 <br />