NCC190550_NOT Signed Certification_20201110

9CG01 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 StormVila ter Program at:
Division of Energy, Mineral &Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.:
Name of Project:
Per NC General Statute 143-215.68 (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:
JCJ 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:
* Legally Responsible Person: l
Title of Leg Responsible Perso :
Signature: I C No
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G `ass
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Date: l!• /p-�2t�o1D
* 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 8, Item (6) of the NCG010000 permit.

11 /10/2020
New Submission
NOT Request Form - Construction Stormwater
NCG01 or NCG25
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NORTH CAROLINA This form is to request Notice of Termination (NOT) for a existing coverage under the NC NPDES Stormwater
Environmental Quality General Permit for Construction Activities
Certificate of NCC190550
Coverage (COC) No. * Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name
Clifton Drive 16" Sanitary Sewer Main Relocation
Address
Clifton Drive, Hope Mills, NC
County
Cumberland
Latitude
34.9700
Longitude
-78.91 g2
Permittee Listed
Fayetteville PWC
Legally Responsible
Joseph Glass
Individual
NC Reference No.
NCG01-2019-0550
E&SC Plan ID
CUMBE-2019-131
Original NOI Tracking
11879
No. *
Date COC Issued *
06/10/2019
Prior Rescission Date
This Feld will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:
Reason for QQ Project Closed -Out
Termination of p Sale (Another Owner/Operator will apply for a new COC)
Coverage* Q Mistake or Invalid Coverage
Q Other
https://edoes.deq.nc.gov/Forms/NCG01-Termination 1/3

11 /10/2020
New Submission
Addional Explanation More information about the basis of this request, if needed.
For Project Close-out, you must provide documentation below:
Final Close-out 11/4/2020
Inspection Approval*
Project Close-out Upload
Approval Clifton Drive Sanitary Sewer Main Replacement.pd... 58.79KB X
Documentation *
Must be PDF format
North Carolina General Statute 143-215.613 (i) provides that:
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; 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 device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* 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 * x
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Type Name* Joseph E. Glass
Title * Water Resources Engineering Manager
Organization * Fayetteville Public Works Commission
Date * Date captured on form submission
Email for [e-mail]
Confirmation *
Contact Telephone* [phone]
https://edocs.deq.nc.gov/Forms/NCG01-Termination 2/3

11/10/2020 New Submission
NOT Certification Upload
Form * Must be PDF Format
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM
(https://files.nc.gov/ncdeq/Energy%20Mi neral%20and°/`2OLand%2OResources/Stormwater/N PDES%2OGeneral
eNOT-Certification-Form-20190508-DEMLR-SW.pdf) to The Stormwater Program at the address on the form for the
application to fulfill federal requirements.
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Submit Save as Draft
https://edocs.deq.nc.gov/Forms/NCG01-Termination 3/3