NCC190762_NOT Signed Certification_20201109

NCGo1 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, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Genera! Permit Certificate of Coverage (COC) No.: iV CC Iqo,- t'i 2
Name of Project: 6a5ou 6-e , e,
Per NC General Statute 143-215.6E (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 nalty of law, I certify that:
LEI, 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: A 4,,,41 S74)e zr�irTQ/,,
* Legally Responsible Person:
Title of
Signatu
* IMPQRTANTNOTE. 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.

ab" 5u7E
NORTH CAROLI NA
Environmental quaNty
Certificate of NCC190762
Coverage (COC) Enter the Certificate of Coverage Number (Use capital letters)
No. *
Information associated with this permit
Project Name
Beeson Creek Outfall Stabilization
Address
1143 Constantine Ct., Kernersville, NC
County
Forsyth
Latitude
36.0960
Longitude
-80.0830
Permittee Listed
North State Environmental, Inc.
Legally Responsible
Brandon Spaugh
Individual
NC Reference No.
NCG01-2019-0762
E&SC Plan ID
Forsy-2019-042
Original NOI
12846
Tracking No.*
Date COC Issued*
06/27/2019
Prior Rescission
This field will populate only if COC has already been rescinded.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Addional fvbre information about the basis of this request, if needed.
Explanation
For Project Close-out, you must provide documentation below:
Final Close-out 11/1/2019
Inspection
Approval*

Project Close-out Constantine Warranty Agreement - signed.pdf 352.03KB
Approval Mast be FDFforrrat
Documentation *
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyof a Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
* Pr 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.
'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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature *
Type Name* Brandon Spaugh
Title * Project Manager
Organization* North State Environmental, Inc.
Date * 10/28/2020
Email for [e-mail]
Confirmation*
Contact Telephone* 3362408257
NOT Certification NC DEMLR Stormwater Program - NCG01 Notice of
35.45KB
Form*
Termination Cert Form - 10.28.2020.pdf
Mast be FDF Format
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM to The Stormwater Program at the address on
the form for the application to fulfill federal requirements.