NCC190653_NOT Signed Certification_20220504

N
JOHNSTON COUNTY PUBLIC UTILITY DEPARTMENT
SEDIMENTATION INSPECTION REPORT
309 E. MARKET STREET, SMITHFIELD, N C 27577-TELEPHONE [phone]
inspection Information
Date: 4/29/2022
Date of Inspection: 4/29/2022
Inspection by: Shannon Stanley
Others Present: Click or tap here to enter
Photos: ❑ Yes N No
Weather and Site Conditions:
Sunny and workable
vevelODmenvuwner information
Type of Inspection
❑ Initial Inspection
N Routine Site Inspection
❑ On -Site Meeting
❑ Progress Inspection
❑ Final Inspection
❑ Plat Inspection
❑ Spot Check Inspection
❑ Complaint Inspection
Construction Stage
❑ Pre -Construction
❑ Initial Grading
❑ Infrastructure
❑ Temp Site Stabilization
N Vertical
N Final Site Stabilization
Project Name: Yorkshire Village Project Number: 19-057-P
Project Location: NC HWY 96 This Report Sent To: Click or tap here to enter text.
Email:::Iick or tap here to enter text.
N File Copy
Land Owner of Record: Person Financially Responsible for Land Disturbing
Insert Land Owner. Activity: ❑ Same as owner
Click or tap here to enter text.
6. Comments/Notes:
Routine site inspection. The erosion control permit for Johnston County is closed.
7. Corrective Actions:
a. n/a
8. Photos:

NCGa1 Notice of Termination (NOT) Certification Form
Directions:
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 SEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.:
Name of Project:
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: fo i l ci ild ' jVC_
*Legally Responsible Person: LAC,''; �, �S _ A C
Title of Legally gesliQnsible Pef,son: d ' r I e' J e
*Signature:
Date:
Print Name and Title of Sign'kq�n/y 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 e, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.