NCC203430_NOT Closeout Documents_20220920

Public Works Department
801 SE Service Rd
4n ve
#; Southern Pines, NC
Phone: [phone]
Fax: [phone]
Emm
20-3387 Soil and Sediment Control Closeout
SITE ADDRESS: 3139 AIRPORT RD CLOSED: 4/17/2020
PROJECT NAME: Tree Removal at Tylers Ridge EXPIRES:
To whom it may concern:
A final inspection of the Soil Erosion and Sediment Control Plan for the above referenced
project has been conducted. Permanent ground cover sufficient to restrain erosion has
been established. No additional self -monitoring or self -inspections are required. All
requirements of the plan have been met and properly completed.
You are reminded of the requirement to maintain any permanent structures of this plan.
Receipt of this letter is notification that the erosion control project plan is completed and is
being removed from our active file. Any further development will require the submittal of a
new plan for review and approval. Termination of coverage under the NPDES General
Stormwater Permit for Construction Activities should be requested by the permittee via a
Notice of Termination. Please note that this correspondence must be uploaded as part of
completing the Notice of Termination process.
If I can be of further assistance, please contact me at 910-692-1983.
Sincerely,
I�,��'��r� ����:i7„• "die, �� � 'U
Pr'A
James Michel, PE, MBA
Town Engineer / Asst. Public Works Director

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 forth to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" 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.: '}-] C.0 Z03 q3o
Name of Project: �y 14 �;�a� Q,�4V4-ah, VtA10 CL.C. - T, itA Q:
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 knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: / (C�S
*Legally Responsible Person: � 4'^CS CS d��^+�`1
Title of LegalV,,,Responsible Person:
*Signature:
Date: 7O zo>'Z
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 1V, 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.