NCC202832_NOT Signed Certification_20211005

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 signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`h 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.: NCC202832
Name of Project: Wilkes County Airport - Samaritan's Purse Hangar Building
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: Samaritan's Purse
*Legally Responsible Person:
Title of Legally Responsible Person:
*Signature:
101512021
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
Ronald E. Wilcox, Chief Operating Officer
*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 1V, Section B, item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part 1V, Section B, Item (6) of the NCGO10000 permit.

North Carolina Department of Environmental Quality
Land Resources: 450 W. Hanes Mill Road, Suite 300, Winston-Salem, NC 27105 (336)
776-9800
County: Wilkes Project: Wilkes County Airport - Samaritan's River basin: Yadkin-PeeDee
Person financially responsible: Samaritan's Purse - Ronald E Wilcox Project #: WILKE-2020-012
Address: PO Box 3000, Boone, NC 28607
1. Project Location: Wood Wallace Dr, North Wilkesboro
Pictures: No
2. Weather and soil conditions: 70's clear Initial inspection: No
3. Is site currently under notice of violation? No
4. Is the site in compliance with S.P.C.A, and rules? Yes If no, check violations below:
5. Violations:
6. Is the site in compliance with NPDES Permit NCG010000 Construction Stormwater requirements? Yes
Describe:
7. Has sedimentation damage occurred since last inspection? No IfYes, where? (check all that apply)
Degree of damage:
8. Contact made with (name): no one
Inspection report: Sent Report
9. Corrective action needed:
Title:
Date given/sent: September 30, 2021
10. Comments: Permanent ground cover sufficient to restrain erosion has been established. No additional
self -monitoring or self -inspections are required. Project is released. Termination of
coverage under the NPDES General Stormwater Permit for Construction Activities should be
requested by the permittee via Notice of Termination.
Reported by: Tim Latham Others present:
Date of inspection: September 24, 2021 Time arriving on site: 2:25 pM Time leaving site: 2:45 PM
cc: [e-mail]; Jason.blackwell{g irvannoy.com;