NCC200342_NOT Signed Certification_20200914

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 form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.:. 4 + W CA6634a
Name of Project: Q 0,0t✓
Dond 'Trazl Lot 01 ra.d
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 enalty 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: L' V ( (G i i.L,G
* Legally Responsible Person: 6Me-4 [- U,12ba✓d
Title of Legally Responsible Person:
Signature:
* 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 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.

Certificate of Coverage
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCG010000
NC Reference No. NCG01-2020-0342
Certificate of Coverage No. NCC200342
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and regulations
promulgated and adopted by the North Carolina Environmental Management Commission, and the Federal Water
Pollution Control Act, as amended,
LRIG, LLC
is hereby authorized authorized to discharge stormwater associated with CONSTRUCTION ACTIVITIES to surface waters
of North Carolina from a site located at:
Beaver Pond Trail Lot Grading
5700 Beaver Pond Trail
Pfafftown
Forsyth County
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in N.C. General Permit
No. NCG010000.
This Certificate of Coverage is affiliated with E&SC Plan Project No. EN1900181
This Certificate of Coverage shall become effective 1/28/2020.
This Certificate of Coverage shall remain in effect for the duration of the General Permit or until rescinded.
for S. Daniel Smith
Director, Division of Energy, Mineral, and Land Resources
By the Authority of the Environmental Management Commission