NCC192394_NOT Signed Certification_20231129

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 122.221
General Permit Certificate of Coverage (COC) No.: NC C l92 39�
Name of Project: 64.of/r2.DAtE ,A4714"rsr
Per NC General Statute 143-215.68(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,andaccurate.i
Legally Responsible Organizational Entity: tt. erte CGOr ertOdice L Le
*Legally Responsible Person: /I.e/14C4 W fchverik
Title of Legally Responsible:rson: �/!cc /4e/il'f
*Signature: //�'' ' Date: // ! t>
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
�eanc�i t✓ cre liWeH1 , Urtc ld/&t'4'4,- Adi-to/r Cid ihree4 44 C
*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 INSPECTION REPORT (City of Winston-Salem/Forsyth County)
Winston-Salem Field Operations Department Permit#: I EN1900097
Erosion Control Division
P.O. Box 2511 Date: 5/31/2023
Winston-Salem, NC 27102
Report by: { Wesley Williams
Revised 1-1-20 Phone: [phone]
Project:
Cloverdale Apartments Location: 2326 Cloverdale Avenue
1. Pictures:("x"One)Yes: No:X
2. Potential for NPDES Violation:("x"One) Yes: No:X Describe:
3. Weather and soil conditions: Cloudy/Wet Initial inspection:("x"One) Yes: No:X
4. Is site currently under notice of violation? ("x"One) Yes: No:X
5. Is the site in compliance with S.P.C.A.and rules? ("x"One) Yes: No: X If no,check violations below:
6. Violations: ("X"all applicable sections)
()--- No approved plan,[UDO Sec.8.4.6(G);&G.S. 113A-57(4)and l5A N.C.A.C4B.0107(c)]
()•-- Failure to follow approved plan,[UDO Sec.8.4.19(A);&G.S. 113A-61.1]
()--- Failure to submit revised plan,[UDO Sec.8.4.17(B)(5);&G.S. 113A-54.1(b)and 15A N.C.A.C.48.0118(a)]
()--- Failure to provide adequate groundcover,[UDO Sec.8.4.6(D)(1)(b);&G.S. 113A-57(3);&15A N.C.A.C.4B.0007(b)or ISA
N.C.A.C. 4B.0124(e))
()--- Insufficient measures to retain sediment on site,[UDO Sec.8.4.6(D)(1)(a);&G.S. 1]3A-57(3)]
()--- Failure to take all reasonable measures, [UDO Sec.8.4.4(B);&15A N.C.A.C.4B0105)
()--- Inadequate buffer zone, [UDO Sec.8.4.6(A);&G.S.113A-57(1)]
()--- Graded slopes and fills too steep,[UDO Sec.8,4.6(B)(I)(a,b,c),&G.S. 113A-57(2)or 15A N.C.A.C.4B.0124(d)l
()--- Unprotected exposed slopes,[UDO Sec.8.4.6(B)(1)(t);&G.S. 113A-57(2)]
()--- Failure to install and maintain erosion control measures,[UDO Sec.8.4.12;& 15A N.C.A.C.48.0113]
()--- Failure to keep current self-inspection records,[G,S.113A-54.1&15A NCAC 04B.01311
()--- Other(describe):
7. Contact made with(name): Christian Banda Title Lomax Construction
8. Contact Method; phone#() email(X) fax#() letter() person()
9. Corrective actions needed:
No corrective actions needed at the time of inspection.
10. Comments:()No devices in place()Additional devices needed()Devices need maintenance()Devices in&functioning
()No seeding noted()Partially seeded(X)Areas seeded(No)Off-site sedimentation(Yes)Project in compliance
All phases of construction and grading are complete. The site is in stable condition per the approved erosion control plan.
I I
11. Others present: I