TCEQ office use only
TPDES Permit Number: TXR15 __ __ __ __ -NO
GIN Number: __ __ __ __ __ __ __
A.
TPDES Permit Number: TXR150000
B. Construction Site Operator
Name:
Mailing Address:
Customer Reference Number: CN
City:
Country Mailing Information (if outside USA) Territory: N/A
State: Texas
Country Code: N/A
Phone Number:
E-mail Address:
Fax Number:
Extension:
C. Project / Site Information
Zip Code:
Postal Code: N/A
Regulated Entity Reference Number: RNN/A
Name:(Include the CSJ#)
Physical Address:
Location Access Description:
City:
County:
Zip Code:
D. Contact - If the TCEQ needs additional information regarding this application, who should be contacted?
Name:
Title:
Phone Number:
Extension:
Fax Number:
E-mail Address:
E. Certification
I certify under penalty of law that authorization under the TPDES Construction General Permit (TXR150000) is no
longer necessary based on the provisions of the general permit. I understand that by submitting this Notice of
Termination, I am no longer authorized to discharge storm water associated with construction activity under the
general permit TXR150000, and that discharging pollutants in storm water associated with construction activity to
waters of the U.S. is unlawful under the Clean Water Act where the discharge is not authorized by a TPDES permit.
I also understand that the submittal of this Notice of Termination does not release an operator from liability for any
violations of this permit or the Clean Water Act.
Construction Site Operator Representative:
Prefix:
Last:
First:
Middle:
Suffix:
Title:
Signature:
Date:
If you have questions on how to fill out this form or about the storm water program, please contact us at (512) 239-4671.
Individuals are entitled to request and review their personal information that the agency gathers on its forms. They may
also have any errors in their information corrected. To review such information, contact us at (512) 239-3282.
The completed NOT must be mailed to the following address:
Texas Commission on Environmental Quality
Storm Water & General Permits Team; MC -228
P.O. Box 13087
Austin, Texas 78711-3087
TCEQ-20023 (02/03)
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