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STATEWIDE SANITARY SEWER SYSTEMS GENERAL ORDER 2022-0103-DWQ <br />ATTACHMENT C-NOTICE OF TERMINATION <br />1.Enrollee Information <br />Enrollee Name:___________________________________________________________ <br />WDIDNo:________________________________________________________________ <br />Legally Responsible Official Requesting Termination of Coverage:___________________ <br />First and Last Name:____________________________________________________ <br />Title:_________________________________________________________________ <br />Phone:_______________________________________________________________ <br />Email:________________________________________________________________ <br />Mailing Address:__________________________________________________________ <br />City,State,Zip:___________________________________________________________ <br />County:_________________________________________________________________ <br />Sanitary Sewer System Name(s) or Unique Identifier(s):___________________________ <br />Regional Water Quality Control Board(s):_______________________________________ <br />Signatureand Date:________________________________________________________ <br />2.Basis of Termination <br />Explanation of termination, including subsequent regulatory coverage and subsequent <br />owner/operator of enrolled sanitary sewer system, as applicable: <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />________________________________________________________________________ <br />ATTACHMENT C NOTICE OF TERMINATIONDecember 6,2022 <br />C-1 <br /> <br />