NCC191328_NOT Signed Certification_20220829

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 signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6ta 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 CPR 122.22]
General Permit Certificate of Coverage (COC) No.: 11166 / q ! 2,0
Name of Project: ",e�—fR e5614 —Z. q
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:
*Legally Responsible Person: / ,40LAPty, '5 ,
Title of Legally Responsible Person:._ 014tVA
*Signature: Ali �- Date:
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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 NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.

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NOF11 H CAI OLINAD IEQ// Y
nc0ar9 . of Environmental tivali
Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCG010000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC191328
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name ECM I HIGH TEMP HOTWATER DIST. SYSTEM REPLACEMENT
Address TW ALEXANDER DRIVE, DURHAM, NC
County Durham
Latitude 35.8822
Longitude-78.8739
Permittee Listed MID -ATLANTIC INFRASTRUCTURE SYSTEMS, INC.
Legally Responsible THOMAS 13UNN
Individual
E&SC Plan ID DURHA-2019-019
Original NOI Tracking 14707
No.*
Date COC Issued* 08/1312019
Prior Rescission Date
This field will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:
Reason for Q Project Closed -Out
Termination of Q Sale (Another Owner/Operator obtained new COC)
Coverage * O Mistake or Invalid Coverage
0 Other

Additional More information about the basis of this request, if needed.
Explanation CLOSE OUT INSPECTION REPORT IS ATTCHED.
For Project Close-out, you must provide documentation below. Please note, a Certificate of Occupancy
is not sufficient close-out documentation. You must provide a final inspection report or correspondence
from the authority that approved the Erosion and Sediment Control (E&SC) Plan.
Erosion Control Plan 8/17/2022
Close-out Date*
Erosion Control Plan Upload
Close-out DURHA-2019-019 20220826 INSPRPT.pdf (blob:... 201.15KB 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,
Important: The person who electronically signs this Certification must be the same person who signs the paper NOT
Certification Form (uploaded below). If that person is signing on behalf of the Permittee, that individual must be an
authorized responsible person within the same organization as the Permittee.
"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 General Permit, For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature * X _4
'-w�"�� r�llfl1Y
Type Name* Mitch Bunn
Title * Project Manager
Organization* Mid -Atlantic Infrastructure Systems, Inc.
Date* Date will be captured on form submission

Email for
Confirmation
Contact Telephone
[e-mail]
19196185916
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link)
(https:l/files.nc.gov/ncdeq/Energy%20Mineral%20and%20Land%2OResources/StormwateriN PDES°/`2OGeneral%20
eNOT-Certification-Form-20210514-DEMLR-SW.pdf) to The Stormwater Program at the address on the form for the
application to fulfill federal requirements. You must also upload a copy of that completed below:
NOT Certification
Form
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