NCC201143_NOT Signed Certification_20220627

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, 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.
Nc r✓ ad11 Y,3
Name of Project: QCOE /tAr44 [/i z-+46e l Len,-- 1-1 , ��~38
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 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.
Legally Responsible Organizational Entity: efly-*A-2 e5'cWwrlu
*Legally Responsible Person: JAN C. e in 215
Title of Legally Responsible Person: pxltrl'at'-IT
*Signature:
Date: "14? 2
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 Port IV, 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: Systel Building, 225 Green Street, Suite 714, Fayetteville, NC 28301-5094
[phone]
Olde Mill Village Lots 1-9, 35-38,
County: Harnett Project: 51-52, 61, 63 River basin: Cape Fear
Person financially responsible: Dan Ryan Builders - day C Lewis, Division Project #: HARNE-2020-083
President NPDES NCG010000 COC: NCC201143
Address: 3131 RD1U Center Drive, Suite 202, Morrisville, NC 27560
1. Project Location: Old Mill Road, Fuquay-Varina
Pictures: No
2. Weather and soil conditions: sunny, workable soils 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 If Yes, where? (check all that apply)
Degree of damage:
8. Contact made with (name): Ben Areno Title: Land Development Manager
Inspection report: Sent Report Date given/sent: May 18, 2022
9. Corrective action needed:
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 (NCG010000) must be requested by the pennittee via a Notice of Termination (NOT).
The NOT is available at: https://edocs.deq.ne.gov/Forms/NCGOI -Termination. Please note that
this correspondence must be uploaded as part of completing the NOT process.
Reported by: Mike Lawyer Others present: Mike Lewis
Date of inspection: May 16, 2022 Time arriving on site: 10:10 AM Time leaving site: 10:30 AM
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