Notice of Termination (NOT) Request - NPDES Stormw_ConcordStreams_Aug2023 (2).pdf

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(COC) will be rescinded.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 NCC201635
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name Concord Streams Restoration Stricker Branch
Address 940 Concord Pkwy N, Concord, NC
County Cabarrus
Latitude 35.4286
Longitude-80.6108
Permittee Listed North American Pipeline Management
Legally Responsible Allen Robinson
Individual
E&SC Plan ID CABAR-2017-097
Original NOI Tracking 24651
No. *
Date COC Issued * 04/23/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:
Reason for U Project Closed -Out
Termination of Q Sale (Another Owner/Operator obtained new COC)
Coverage* Q Mistake or Invalid Coverage
Other
Additional More information about the basis of this request, if needed.
Explanation The U.S. Army Corps of Engineers as the Financially responsible party listed on the
attached final inspection report request the closure of this permit.
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 5/10/2023
Close-out Date*

Erosion Control Plan Final_lnspection_Report.pdf 55.29KB
Close-out Must be PDF format
Documentation *
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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature*
Type Name* Jeremy Smith
Title * Chief of Construction
Organization* U.S. Army Corps of Engineers - Construction Division
Date * 08/10/2023
Email for [e-mail]
Confirmation*
Contact Telephone* 910-251-4642
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link) 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 NOT Certification Form (signed).pdf 43.25KB
Form * Must be PDF Format
Additional Email [e-mail]
(Optional)