NCC210908_NOT Closeout Documents_20220401

NCGO1 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 Varr �,IL.'Piil� F+ RNI UNT1!. 'I',7'„IF1 NOTREQUE5T BEEN REVIEWED d0FIbtOVED
-1 AN ORIGIV il. "iTLIRE (NOT I;..l IA-L) [40 CF12�.; 11E F�7M YOU lU=i3E C�MPL� fi:i I11'i
General Permit Certificate of Coverage (COC) No.: i�JC-(- 4 fir.
Name of Project: F r z�� ?� "f +r� -. I;, Cr "-) 1, b
Per NC General Statute 143-215.68 (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:
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.
Legally Responsible Organizational Entity: C--y" orr', firC'
*Legally Responsible Person:
Title of Legally Responsible Person: —J '� rA
7
*Signature:
Print Name aril Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* iMPORTANTNOTE. 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 8, item (6) of the NCG010000 permit.
For more information on signatory requirements, see Port IV, Section 8, item (6) of the NCGO10000 permit.

Division of Energy. Mineral and Land Resources
County-: Burke Project. Breeden Substation Improvements River basin: Catawba
Person financiallyresponsible: Duke Energy Carolinas, LLC Project y BLTRK-2021-016
Address: 400 South Tryon Street, Suite 30C Charlotte, NC 28202 Case 4
1. Project location: Burkemont Avenue, Morganton
Pictures: No: ❑ Yes: 0 Video: ❑ lligitai; Q
2. Weather and soil conditions: Sunny, Wet First inspection: Yes: Q No: ❑
3.a. Has NCGal Certificate of Coverage been issued at time of inspection? Yes: 0 No: ❑
3.b. NCG01 Certificate of Coverage onsite? Yes: 0 No: ❑ Not Applicable: ❑
4. Is site currentky under notice of violation? Yes: ❑ No:
5. Is the site in compliance,40th S.P.C.A. and rules? Yes: ❑✓ No: ❑ If no check violations below:
6. Violations:
❑ a. No approved plan. G,S, 113A-57 (4) and 15A N.C.A.0 4B.0107(c)
❑ b, Failure to follow• approved plan, G.S, 113A-57(5)
❑ c. Failure to submit revised plan_ U.S. 113A-54,1(b) and
ISA N.C.A.C. 4B.0I18(a)
❑ d. Failure to provide adequate groundcover, 0.S.113A-57(3) and
15A N,C.A.C. 413.0107(b)
❑ c. Insufficient measures to retain sediment on site, G.S. 113A-57(3)
❑ f. Failure to take measures to protect property. 15A N,C.A.C: 4B4O105
g. inade.quatc buffer zone, G,S, 113A-57(l)
It, Graded slopes and fills too steels.
G S. 113A-57(2) or I5A N.CA.C, 4B4O124(e)
❑ i. Unprotected exposed slopes. G.S, 113A-57(2)
❑ j, I ailure to install and maintain measures,
15A N.C.A.C. 413.0113
z
❑ k. Failure to self -inspect G.S. 113A-54.I(e) and
15A N.C.A.C. 4B,GL; i
❑ 1. Other (describe)_ - --
7. Is the site in compliance With NPDES Permit NCG 01000i1? Yes- © No: ❑ Not Applicable: ❑ if too_ check violations below,
❑ in. Discharge without a pennit G.S. 143-215. l(a) and
I SA N.C.A.C. 0,2H ,0126
❑ it, Fail lire to develop or adhere to approved plan,
NCG 010000, Part I
❑ o. Failure to manage construction site pollutants, NCG 010000 Part M F
❑ p. Failure to provide ground stabilization. NCG 010000 Part 11, l
❑, q. Failure to meet self -inspection, reporting and record -keeping.
requirements, NCG 01000t1, fart III
❑ r. Failure to install and maintain BMP's,
NCG 010000 Part 1I. ('T.2-3
❑ s. Failure to dewatcr sediment basin from surface.
NCG 010000, Pan I1,13.8 oi• GA
❑ 1, B),pass of stormwater control facilities.
NCG 010000, Part TL 0.5-6
❑ w Other (describe) --
8. Site out of compliance with NOV deadline? Yes: ❑ No: ❑ Not Applicable: Q
9. Has sedimentation damage occurred since last inspection or at 1" inspection'' Yes: ❑ If yes, where? (check all that apply) No- lJ
Lake natural `vatereourse on the traci; ❑ Lakermqtural xalcrcourse of the tract: ❑ Other property: ❑
Description:
Stormµ'ater Discharge Outfall «ilh sediment loss: .
Degree of damage: slight; ❑ moderate: ❑ severe ❑
10. Contact made with (name); Title:
Inspection report given: ❑ or sent: ❑,✓ to person financially responsible, Date givenfscnt: 2110/22
11. Corrective actions needed:
Inspection performed per request for permit closeout. At the time of inspection, no corrective
actions were noted and the site is sufficiently stabilized. Site is approved for permit closeout. Please file a Notice of
Termination forth by visiting deqnc.gov/NCG0 I
Report by Mack Granger
Date of inspection: 2/8/22
Others present:_
Time arriving on site: 10:05 AM
Time leaving site: 10:30 AM
Page 1 of 3

County : Burk* project:
Division of Energy. Mineral and Land Resources
Breeden Substation Improvements Project # BURKE-2021-016
(.:Heck only one box. if closing out project.
Permanent ground cover sufficient to restrain erosion hag been established. No additional seifAnspection or monitoring is required. Project is
released and coverage under the NPDES General Stormwater Permit for Construction Activities is terminated.
0 Permanent ground rover sufficient to restrain erosion hag been established. No additional self -inspection or monitoring is required and the
project is released under the `;PC.1. 1f this project itas a Certificate of Coverage (COC) corder the ti(Y:#31 permit, then complete the electronic
Notice "Termination (eNO'r) form at deq.nc.gov1NC'G()1.
Repoli by: Mack Granger Date of inspection: 2/8/22 Page 3 of 3