NCC191489_NOT Signed Certification_20200619

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6ch Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.. NCC191489
Name of Project:
Ocean Isle Beach Town Park
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES
Stormwater Permit for the subject facility. I am familiar with the information contained in this
request, and to the best of my knowledge and belief, such information is true, complete, and
accurate.
Legally Responsible Organizational Entity: Town of Ocean Isle Beach
* Legally Responsible Person:
Title of Legally
Signature:
Daisy Ivey
nsible Person, Town Administrator / Finance Officer
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

North Carolina Department of Environmental Quality
Land Resources: 127 Cardinal Drive Extension, Wilmington, NC 28405 [phone]
County: Brunswick Project: Ocean Isle Beach Town Park River basin: Lumber
Person rinancially responsible: Town of Ocean Isle Beach -Daisy Ivey Project #: BRUNS-2019-081
Address: 3 West Third Street, Ocean Isle Beach, NC 28469
t. Project Location: I 1 E. Second St., Ocean Isle Beach
Pictures: No
2. Weather and soil conditions: sunny and workable
3. Is site currently under notice of violation? No
4. Is the site in compliance with S.P.C.A. and rules? Yes
5. Violations:
6. Is the site in compliance with the NPDES Permit? Yes
Describe:
Initial inspection: No
If no, check violations below:
7. Has sedimentation damage occurred since last inspection? No If Yes, where? (check all that apply)
Degree of damage:
S. Contact made with (name): Elizabeth Nelson Title:
Inspection report: Sent Report Date given/sent: June 11, 2020
9. Corrective action needed:
10. Comments: Project appears complete and stabilized. File will be closed.
Permanent ground cover sufficient to restrain erosion has been established. No additional
self -monitoring or self -inspections are required. Project is released and coverage under
NPDES General Stormwater Permit for Construction Activities is terminated.
Reported by: Connor Musial C . _ ' �_--l�pthers present:
Date of inspection: June 04, 2020 Time arriving on site: 12:30 PIivi Time leaving site: 12:45 PM
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