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f <br /> 3. NO STORM WATER DISCHARGE. None of my facility's storm water discharges directly or indirectly to waters <br /> of the United States (such as a river• lake. stream, ocean, municipal storm drain, eetc,) because: <br /> a. All storm water is retained on site(such as in an evaporation or percola tion pond). <br /> b, All storm water is discharged to a municipal sanitary sewer system, <br /> C. All storm water is discharged to off0te(such as in evaporation or percolation ponds). <br /> 4, REGULATED.BY ANOTHER PERMIT. My facility's storm water discharge is regulated by a separate NPDES <br /> Permit. <br /> NPDES Permit No. <br /> . Date coverage began / �r <br /> 5, NEW FACILITY OPERATOR. There is a new%cility operator of my h'(facili s-. <br /> ) <br /> Date facility(s)was transferred to new facility operator I l� <br /> I Have you notified the new facility operator of the storm water NPDES Permit requirements? Yes No <br /> E <br /> NEW FACILITY OPERATOR INFORMATION <br /> COMPANY NAME CONTACT PERSON <br /> MAILING ADDRESS TITLECITY- <br /> I <br /> 1 <br /> P <br /> 6. NEVER OPERATED FACILITY, I am not and have never been the operator a'fac•' <br /> .. r of ill required <br /> have no responsibilityfor the facility's re p t!` #o re permitted. I <br /> y regulatory compliance. The correct facility operator who has regulatory <br /> Mato <br /> 9 <br /> responsibilityfor rY <br /> the facility is: <br /> CORRECT FACILITY OPERATOR INFORMAi 17N <br /> COMPANY NAME CONTACT PERSON <br /> MAILING ADDRESS TITLE <br /> CITY ATF= <br /> 7. OTHER. Other reason for non-applicability. (If necessary, attach letter or explanation_) <br /> N. CERTIFICATION <br /> I certify under pe6afty of law that I am not required to be pe.,n'rtted under the Industrial Activities Storm Water General <br /> Permit No. 97-03-DWQ for any facility that I operate. I undarrstand that discharging storm water associated with industrial <br /> activity to waters of the United States is unlawful under the Clean Water Act where the discharge,is not authorized by a <br /> NPDES permit. I aril aware that there are significant penal ues for submitting false information,on this form, including the <br /> possibility of fine or imprisonment. I also understand that the submittal of this Notice of Non Applicability does not release a <br /> facility operator from liability for any violations of the General Permit or the Clean Water Act. <br /> PRINTED NAME <br /> TITLE <br /> SIGNATURE DATE / <br /> I <br />