NCC202370_NOT Signed Certification_20220711

Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCG010000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC202370
Coverage (COC) No.* Enter the CerbLealo of Covorago Number (use capdal tellers)
Information associated with this permit:
Project Name Jerry 8 LaTonza Pettus / D I n � D .� U
Address 10434 Annie Oakley Trail`, Mint Hill, NC
County
Mecklenburg
Latitude
35.1770
Longitude
-80.6020
Permitteo Listed
LaTonza Pettus
Legally Responsible
LaTonza Pettus
Individual
EBSC Plan ID
408287
Original NOI Tracking 26507
No.
Date COC Issued* 06/05/2020
Prior Rescission Date This field wall populato only if COC has already been rosunded.
Reason for Rescission/Termination Request:
Reason for Project Closed -Out
Termination of Sale (Another Owner/Operator obtained new COC)
Coverage Mistake or Invalid Coverage
Other
Additional More informcion about the basis of Iles roquest, 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 Erosion and Sediment Control (EBSC) Plan.
Erosion Control Plan 7/14/2021
Close-out Date *
Erosion Control Plan Eronsion-Stormwater Final Inspection - 7-14-21.pdf 120.14KB
Close-out Must be PDF lormai
Documentation'`

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).
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.
Important: The person who electronically signs this Certification must be the same person who signs the paper NOT
Certification Form (uploaded below). If that person is signing on behalf of the Permittee, that individual must be an
authorized responsible person within the same organization as the Permittee.
'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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature*
,rzr� —trrtl
Type Name* self
Title *
Organization
Date *
Email for
Confirmation
Contact Telephone*
Owner
La'Tonza Pettus
06/01 /2022
[e-mail]
7045754166
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link) to The Stormwater
Program at the address on the form for the application to fulfill federal requirements. You must also upload a copy of that
completed below:
NOT Certification Eronsion-Stormwater Final Inspection - 7-14-21.pdf 120.14KB
Form * Must be PDF Format
Additional Email
(Optional)