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NOTICE OF TERMINATION i <br /> For General Permit to Discharge ; <br /> Stormwater Associated with <br /> """���� "��� Construction Activity Permit �t 503 - _ _ _ _ _ _ <br /> �C�O� L�O�G �T <br /> IPleese print in ink or type) Use this Fortn to end permit covere9e unce all consttuction and <br /> soil stabilization measures have been completed. <br /> L Contact Person II. Owner/Representative of Site <br /> Contact Name Phone No. Owner's Name <br /> Phone No. <br /> J Company Name <br /> Company <br /> Mailing Address <br /> Mailing Address <br /> Cm, State <br /> ZiP . 4 City State Zip . 4 <br /> �V, Billin Address <br /> IIL Site Location/Address Concacc Name Pnone No. <br /> Site Name <br /> Street Address (or Location Descriptionl <br /> Company Name <br /> City (or nearest city) Zip + 4 Mailing Address <br /> ��, State Zip • 4 <br /> County <br /> Provide legal description 'rf no address for site (attach separate sheet 'rf necessaryl <br /> � <br /> y. Construction Acti ' <br /> ❑ The site has undergone finai stabilization of all exposed soils through vegetation•or other measures and all <br /> stormwater discharges from construttion activities that are authorized bY this pertnit are eliminated. <br /> Certific8tion of Permittee(S) (Please read the certification statement carefully before signing•) edrite rhar <br /> 'I cerrijy imder penahy ollax'�ali rrornxmer dischmger assoda:ed winc �onmvcLon ncuviry from rh¢ identifi <br /> are mrhvrized by the Nadonal Po(ham�r Disrharge EGminarion System (NPDES) mrd Swu A'aru Dis�ge gauani pe�mir <br /> hmti becn eGminared, or dmr 1 mn no bnger rhe oµner of tht siu. I tmdernm�d d�r bY sub"°aing tlu.;Nodce aJ <br /> Tmninanon, thas I mn no iongtr mchrn:.eG m disrharge sfomn�nter associnsed xdnc �oru[ruaion aaiviry by the genera! <br /> rhe State oJ Washingtan is wlawJu!�md�r the Qean Water <br /> permir, mid rhar discimging poU�am�+s in rwrm�+nzer w xaters oj rhar rhe submiaal oJthi.s Nodee oJ <br /> Aa where the �scharge u nvc mchaized try a NPDES permit. I aLso ro�dcrsrmid L7ofan'oru oJ rhi.s perniir or rhe Clenn R'arer <br /> Termin�sion dnes nvr release the m�ner (or other permiaee)from Gabilirv far mp. <br /> AG." <br /> OwnerlRepresentative's Pnnted Name <br /> Date <br /> OwnerlRepresentative's Signature <br /> ECY 020-87 IRev. 11/95) <br /> (Msrrucrions on back! IAppendix 2) <br />