HomeMy WebLinkAboutNCC190450_NOT Signed Certification_20210625, Notice of Termination (NOT) Certification Form
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.:
NCC 190450
Name of Project: Raw Water Transmission Re lacement Project - Phase II City of Elizabeth Ci
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 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: City of Elizabeth City
* Legally Responsible Person: Dwan Bell
Title of Legally Responsible Person: Public Utilities Director
*Signature:
Date:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* 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: 943 Washington Square Mall, Washington, NC 27889 (252) 946-6481
County: Pasquotank Project: Raw Water Transmission Replacement River basin: Pasquotank
Person financially responsible: City of Elizabeth City - Richard C Olson, City Project #: PASQU-2019-005
Manager
Address: P.O. Box 347, Elizabeth City, NC 27909
1. Project Location: Wellfield Road, Elizabeth City
Pictures: Yes - Digital
2. Weather and soil conditions: cloudy, warm, dry Initial inspection: No
3. Is site currently under notice of violation? Yes
4. Is the site in compliance with S.P.C.A. and rules? Yes If no, check violations below:
5. Violations:
6. Is the site in compliance with NPDES Permit NCGO10000 Construction Stormwater requirements? Yes
Describe:
7. Has sedimentation damage occurred since last inspection? No If Yes, where? (check all that apply)
Degree of damage:
8. Contact made with (name): No one. Title:
Inspection report: Sent Report Date given/sent: June 14, 2021
9. Corrective action needed: None at this time
10. Comments: Permanent ground cover sufficient to restrain erosion has been established. No
additional self -monitoring or self -inspections are required. Project is released, remove
from active files.
Reported by: James Edwards Others present: No one.
Date of inspection: June 08, 2021 Time arriving on site: 10:45 AM Time leaving site: 10:55 AM
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