NCC224219_NOT Signed Certification_20230720

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 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 122.22]
General Permit Certificate of Coverage (COC) No.: N CC- 2 Z4- 2 i 9
Name of Project: OCCAM SANDS N1 7 GczoN[rt i'c't'T 1)11-0-k livv,k04 .,ukem rs
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(must match eNOT): L= `k'^" E* Lk Zz`-Cu-ct"'
*Legally Responsible Person (must match eNOT): D,NhLv t. ork-1ZE,:- , Tx.
*Title of Legally Responsible Person: G' ' x iv\aµAciciz
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
)//4/d/°.-----
*Signatur Date: I/1 /
L 3
* 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.

Sedimentation/Construction Stormwater Inspection Report
North Carolina Department of Environmental Quality
Land Resources: 943 Washington Square Mall,Washington, NC 27889 [phone]
County: Currituck Project: Ocean Sands and Crown Point Ditch River basin: Pasquotank
Person financially responsible:County of Currituck-Donald I McRee,County Project#: CURRI-2023-015
Manager
Address: 153 Courthouse Rd.,Suite 204,Currituck,NC 27929
1. Project Location: NC 12,Corolla
Pictures: No
2. Weather and soil conditions: 90 degrees,cloudy,wet Initial inspection: Yes
3. Is site currently under notice of violation? No
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 NCG010000 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 contact was made. Title:
Inspection report: Sent Report Date given/sent: July 07,2023
9. Corrective action needed:
10. Comments: Permanent ground cover sufficient to restrain erosion has been established.No additional
self-monitoring or self-inspections are required.The project is in compliance and released under the SPCA.The
permittee must request termination of coverage under the NPDES General Stormwater Permit for Construction
Activities(NCGO I)via a Notice of Termination(NOT).The NOT is available at
https://edocs.deq.nc.gov/Forms/NCGOI-Termination. Please note that this correspondence must be uploaded as part
of completing the NOT process.
Reported by: Scott Graboski Others present:
Date of inspection: July 06,2023 Time arriving on site: 10:00 AM Time leaving site: 10:10 AM
CC: