NCC202063_NOT Signed Certification_20210512

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, 61" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC202063
Name of Project
La-Z-Boy Northlake West
Per NC General Statute 143-215.6E (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:
*Legally Responsible Person: Byron Brown
Title of Legally Responsible Person:
*Signature:
Tipperary Sales, Inc
Senior Vice President
Date: 5/12/2021
Print Name and TiTle of Signed (only if authorized individual signing differs from Legally Responsible Person):
*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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
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Depart—t of Envtronme W Q- ity

ENGINEERING B PROPERTY
MANAGEMENT
Grading Permit Notice of Termination
Date:5/12/2021
To: Byron Brown
200 Providence Road
Suite 205
Charlotte, NC 28207
Reference: La-Z-Boy Northlake West
Permit Number: LDGP-2019-00245
You or your firm are on record as the owner or financially responsible party for land disturbing
activity at the subject site covered under the above referenced grading permit number.
Per the completion of your project or your request, the City of Charlotte is closing the grading
permit. Any further grading activity of one acre or more will require an application for a new
grading permit.
If you have any questions or feel the grading permit should remain open, please contact the
Erosion Control Coordinator associated with your project.
Issued by,
James Wilson CPESC
Water Qualitv Administrator
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