Fillable Printable Release of Liability Form Template
Fillable Printable Release of Liability Form Template
Release of Liability Form Template
3150-FM-BWEW0271 10/2015 COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
OFFICIAL USE ONLY
PA
CO-PERMITTEE LIABILITY RELEASE FORM FOR PERMITS
ASSOCIATED WITH 25 PA CODE CHAPTER 102
Applicability: This form may be used by a permittee or co-permittee presently covered under an Individual National
Pollutant Discharge Elimination System (NPDES) Permit for Stormwater Discharges Associated with Construction
Activities, the General NPDES Permit for Stormwater Discharges Associated with Construction Activities (PAG-02), an
Erosion and Sediment Control Permit (ESCP), or an Erosion and Sediment Control General Permit for Earth Disturbance
Associated with Oil and Gas Exploration, Production, Processing, or Treatment Operations or Transmission Facilities
(ESCGP) regardless of when the permit was issued or authorized.
Who May File a Co-Permittee Liability Release Form:
Permittees or Co-permittees, presently covered under a permit referenced above, may submit this release form to the
Department of Environmental Protection (Department) or conservation district when the co-permittee is no longer an
operator of the construction activity at an unstabilized site.
1. PERMIT INFORMATION:
Permit No.:
2. EARTH DISTURBANCE SITE LOCATION:
Facility/Development Name:
Address :
Municipality: County:
Latitude: / '/ " Longitude: / '/ "
U.S.G.S. Quad Map Name:
3. PERMITTEE ACKNOWLEDGEMENT:
Organization/Individual Name:
Address:
City:
State: Zip Code:
Telephone Number:
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3150-FM-BWEW0271 10/2015
I hereby acknowledge that the co-permittee, as identified in Section 4 of this Liability Release Form, has
completed their responsibilities, as they pertain to the permit referenced above, and is withdrawing as a co-
permittee. Upon receiving written approval of this form from either the Department or conservation district, I
understand that the remaining permittee(s) and co-permittee(s), as applicable, shall be jointly and severally
responsible for compliance with all conditions of this permit and associated laws.
Name and Official Title of Permittee
Signature:
Date Signed: , 20
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3150-FM-BWEW0271 10/2015
4. CO-PERMITTEE CERTIFICATION:
I certify, under penalty of law, that I am no longer an operator of the construction activity. I understand that by
submitting this Liability Release Form, I am no longer authorized to conduct earth disturbance activities under the
above referenced permit. I also understand that the submittal of this Liability Release Form does not release a
permittee from liability for any violations of this permit or of the federal Clean Water Act, the Pennsylvania Clean
Streams Law and the regulations promulgated pursuant thereto or from liability for any environmental damages
occurring as a result of any earth disturbance activities conducted at the site. I am aware that there are significant
penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Organization/Individual Name:
Address:
City:
State: Zip Code:
Telephone Number:
Name and Official Title:
Signature:
Date: , 20
ACKNOWLEDGEMENT:
Commonwealth of Pennsylvania
County of
On this, the day of , 20 , before me, a Notary Public, personally appeared
, having a title of within the business
entity of , known to me (or satisfactorily proven) to be the person whose name is
subscribed to the foregoing document, and acknowledged that he/she executed the same for the purposes therein
contained.
IN WITNESS WHEREOF, I have hereunto set my hand and notarial seal.
NOTARY SEAL
________________________________________________ My Commission Expires:____________________
Notary Public
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