NCC203625_NOT Signed Certification_20211008

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, 61h 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.: NCC203625
Name of Project: PNG - Albemarle CP Section 24
Per NC General Statute 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 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: Piedmont Natural Gas Company, Inc.
*Legally Responsible Person: Randy Webb
Title of Legally Responsible Person: Supervisor Field Services, Construction
*Signature:
ate: /01 8 2o2/
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.

North Carolina Department of Environmental Quality
Land Resources: 610 East Center Avenue, Suite 301, Mooresville, NC 28115 [phone]
County: Stanly Project: PNG Albemarle CP Section 24 River basin: Yadkin-PeeDee
Person financially responsible: Piedmont Natural Gas - Randy Webb, Operation Project #: STANL-2021-003
Supervisor
Address: 5601 Cannon Drive, Monroe, NC 28110
I. Project Location: Salisbury Avenue, Albemarle
Pictures: No
2. Weather and soil conditions: dry 80's Initial inspection: Yes
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 NCGO10000 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):
Inspection report: Sent Report
9. Corrective action needed:
Title:
Date given/sent: September 17, 2021
10. Comments: Project complete, closed and deadfiled. Please submit a NOT (notice of termination) to close
out the NCGO 1 coverage.
Reported by: James Moore
Date of inspection: September 15, 2021
cc,
Others present:
Time arriving on site: 12:40 PM Time leaving site: 12:50 PM