NCC201748_NOT Signed Certification_20210519

5/17/2021 New Submission
NOT Request Form - Construction Stormwater
NCG01 or NCG25
This form is to request Notice of Termination (NOT) for a existing coverage under the NC NPDES Stormwater
General Permit for Construction Activities
Certificate of NCC201748
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name
Culver's Kannapolis
Address
910 Brentwood Court, Kannapolis, NC
County
Cabarrus
Latitude
35.4690
Longitude
-80.5900
Permittee Listed
Cognati Enterprises, LLC
Legally Responsible
Larry Luensman
Individual
NC Reference No.
NCG01-2020-1748
E&SC Plan ID
CABAR-2020-050
Original NOI Tracking
24857
No. *
Date COC Issued * 04/30/2020
Prior Rescission Date
This field will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:
Reason for# Project Closed -Out
Termination of O Sale (Another Owner/Operator obtained new COC)
Coverage* O Mistake or Invalid Coverage
Q Other
https://edocs.deq.nc.gov/Forms/NCGO1-Termination 1 /3

5/17/2021
New Submission
Addional Explanation More information about the basis of this request, if needed.
F
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 E&SC Plan.
Final Close-out 11/10/2020
Inspection Approval*
Project Close-out Upload
Approval NC NOT Form.pdf (/Forms/handlers/downloadatta... 1.08MB X
Documentation*
Stormwater SCM Cert.pdf (/Forms/handlers/downl... 175.91 KB X
Must be PDF format
North Carolina General Statute 143-215.6B (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).
Q 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.
*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 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature* x
Type Name* Larry Luensman
Title* LLC Manager
Organization* Cognati Enterprises LLC
Date* Date captured on form submission
Email for [e-mail]
Confirmation*
https://edocs.deq.nc.gov/Forms/NCGO1-Termination 2/3

5/17/2021
New Submission
Contact Telephone* 6183448780
NOT Certification Upload
Form* NC NOT Form. pdf (/Forms/handlers/downloadatta... 1.08MB �(
Must be PDF Format
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM
(https://files.nc.gov/ncdeq/Energy%20M ineral%20and%20Land%20Resources/Stormwater/NPDES%20General
eNOT-Certification-Form-20210514-DEMLR-SW.pdf) to The Stormwater Program at the address on the form for the
application to fulfill federal requirements.
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https://edocs.deq.nc.gov/Forms/NCGO1-Termination 3/3