NCC200159_NOT Signed Certification_20220210

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, 6th 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.: or-(Z ,200 157
Name of Project: �j,\-'tw�r. z �cC k
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 o 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. 1 1Q
Legally Responsible Organizational Entity: dcx:-L'v ellj 14� ✓o I((.•, ., /YMo
*Legally Responsible Person: ��% /✓�rSs��
Title of Legally Responsible Person:
*Signature: . --�//' 'y - Date: 1 -9.
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 cAROUNA
EnvLnnmenta!CAW Ny
NOT Request Form - Construction Stormwater
NCGO1 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 NCC200159
Coverage (COC) Enter the Certificate of Coverage Number (Use capital letters)
No. '
Information associated with this permit
Project Name
Biltmore Park Subdivision
Address
Flatbush Drive, Huntersville, NC
County
Mecklenburg
Latitude
35,3815
Longitude
-80.9238
Permittee Listed
Brookwood Home Building
Legally Responsible
Randy Nassar
Individual
NC Reference No.
NCG01-2020-0159
E&SC Plan ID
EPM #398317
Original NOI
20501
Tracking No.*
Date COC Issued *
01/14/2020
Prior Rescission
This field will populate only if COC has already been rescinded.
Date
Reason for Rescission/Termination
Request:

Reason for (+fir Project Closed -Out
Termination of ( Sale (Another Owner/Operator obtained new COC)
Coverage * Mistake or Invalid Coverage
Other
Additional More information about the basis of this request, if needed.
Explanation
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 9/8/2021
Inspection
Approval *
Project Close-out Biltmore Park EC Final Inspectio EPM 398317.do... 172.77KB
Approval Biltmore Grading Final.pdf 606.76KB
Documentation * Must be PDF format
North Carolina General Statute 143-215.6E (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).
1, 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 *
Type Name* Randall Nassar

Title ' Member/MGR
Organization * Brookwood Home Building
Date k 02/04/2022
Email for [e-mail]
Confirmation *
Contact Telephone* 7043611356
NOT Certification Biltmore Grading Final.pdf 606.76KB
Form * Must be PDF Format
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM to The Stormwater Program at the address
on the form for the application to fulfill federal requirements.
Additional Email
(Optional)