NCC190631_NOT Signed Certification_20191126

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 form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (CCQ No.: ge Giy i 00 b o
Name of Project:
Per NC Generol5tatute 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 o fine not to exceed ten thousand dollars ($10,000).
Under p 'ally of law, I certify that:
, 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: �1Qt/1�4SfQ tt_D�it�I I1ic—
* Legally Responsible Person: G ', 1� M V r-
Title of Legally Responsible Person:
Signature:
Date:
* 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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CITY OF BURLINGTON
ENGINEERING DEPARTMENT
W. Todd Lambert, P.E.
City Engineer
November 12, 2019
EROSION CONTROL PERMIT CLOSEOUT NOTIFICATION
MO Custard LLC
60 Fourth Street
Camdenton, MO 65020-
Subject: Andy's Frozen Custard
Huffman Mill Road
Alamance Tax Map: 3-21-25A
Land Disturbing Permit Number: 647
Dear Mr. Greg Anderson:
On November 4, 2019, personnel of this office inspected the above referenced project located off
Huffman Mill Road in Alamance County, North Carolina. This inspection was performed to determine
compliance with the City of Burlington Soil Erosion and Sedimentation Ordinance. The inspection
involved a land -disturbing activity of approximately 1.02 acres being conducted.
It is our understanding that you and/or your firm are responsible for this land -disturbing activity. The
purpose of this letter is to inform you that permanent ground cover sufficient to restrain erosion has
been established. No additional self -monitoring or self -inspections are required and the project is
being released from further erosion control inspection requirements. Termination of coverage under
the NPDES General Stormwater Permit for Construction Activities should be requested by the
permittee via a Notice of Termination.
Please contact the Engineering Department if you have questions or concerns relating to the close out
process.
cc: Mr. Zac Lentz
Division of Land Resources
450 West Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Mr. Jay Mebane
Chief Inspector
Sincerely,
Z, �4�
Brandon Holt, PE
Erosion Control Administrator
Mr. Jared W. Diemel, PE
Civil Engineering Design Consultants
10820 Sunset Office Drive, Suite 200
Saint Louis, Missouri 63127
Mrs. Carolyn Buckner
Stormwater Manager
NIAILING ADDRESS:
423 S. I,EXINGTON -WE.
BURLINGTON, NC 27215
TF X1'11( )'.I : �336) 222-5050
1 \: 336) 513-546'
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