NCC200781_NOT Signed Certification_20220314

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 122.22]
General Permit Certificate of Coverage (COC) No.:
NCC200781
Name of Project: Wayne Farms 2020 Processing Plant Addition
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 I<nowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: Wayne Farms LLC
*Legally Responsible Person: Jeremy Kilburn
Title of Legally Responsible Person: Vice President & General Counsel
*Signature:
3z-
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.

Sedimentation/Construction i iReport
North Carolina Department of Environmental Quality
Land Resources: 450 W. Hanes Mill Road, Suite 300, Winston-Salem, NC 27105 (336)
776-9800
County: Surry Project: Wayne Farms 2020 Processing Plant River basin: Yadkin-PeeDee
Person financially responsible: Wayne Farms, LLC Project #• SURRY-2020-020
Address: 4110 Continental Dr., Oakwood, GA 30566
1. Project Location: E. Atkins St., Dobson
Pictures: Yes - Digital
2. Weather and soil conditions: Sunny, Workable Soils
3. Is site currently under notice of violation? No
4. Is the site in compliance with S.P.C.A. and rules? Yes
5. Violations:
Initial inspection: No
If no, check violations below:
6. Is the site in compliance with NPDES Permit NCGO10000 Construction Stormwater requirements?
Describe:
7. Has sedimentation damage occurred since last inspection? No If Yes, where? (check all that apply)
Degree of damage:
8. Contact made with (name): Jonathan Green Title: Wayne Farms
Inspection report: Sent Report Date given/sent: March 14, 2022
9. Corrective action needed:
Yes
10. Comments: Permanent ground cover sufficient to restrain erosion has been established. No additional
self -monitoring or self -inspections are required. Project is in compliance and released under
the SPCA. Termination of coverage under the NPDES General Stormwater Permit for
Construction Activities (NCGO1) must be requested by the permittee via a Notice of
Termination (NOT). The NOT is available at:
https://edocs.deq.nc.gov/Forms/NCGO1-Termination. Please note that this correspondence
must be uploaded as part of completing the NOT process.
Reported by: Tyler Pearson Others present:
Date of inspection: March 01, 2022 Time arriving on site: 11:00 AM Time leaving site: 12:00 PM
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