NCC214888_NOT Signed Certification with Info_20221025

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the orlginal 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 DE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: n/C--e-a 1 14 P 8
Name of Project: _ �✓� Zvi, ,, fYin i
Per NC General Statute 143-215.6B (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: S / C 11, [ i•-H - , ,� ( V J �-.L �..
*Legally Responsible Person: / //V ( UU t v) J 0, 4 �%
Title of Legal es p nsl r on:
*Signature: Date: /U/ L J-/.Zk
Print
/Name and Titles ofSigned(only if authorized individual signing differrs fromally Responsible Person):
I"!y l�� � Q 74 7 • _ �(�/c.l Nn Nam+ 7 (J ! � l.Ci/� r
* 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.
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Clark, Paul
From: Holden Sabato <[e-mail]>
Sent: Thursday, November 3, 2022 9:58 AM
To: Clark, Paul
Subject: [External] RE: NCC214888
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Paul,
Dan Lacz is no longer with the company so I will be acting as authorized representative. Is there anything else you need
from us for the NOT?
Thanks,
Holden Sabato
Development Director
The Silverman Group
195 Morristown Road
Basking Ridge, NJ 07920
Office: 973-765-0100 x4083
Cell: 862-222-5899
Email: holdensabato(a)silvermanerouo.net
www.siIvermangroup.net
From: Clark, Paul [mailto:[e-mail]]
Sent: Thursday, November 3, 2022 9:53 AM
To: Holden Sabato <[e-mail]>
Subject: NCC214888
Mr. Sabato (Holden),
Hi. As you are aware NCC214888 was rescinded. Please confirm that you are the authorized representative for Dan
Lacz (since he was listed as legally responsible individual in COC database). I thought you had already sent me an email
to this effect, but I think I confused another project for this one. Please also contact me with any questions. Thx.
Paul Clark
Water Supply Watershed Protection Coordinator
Stormwater Program
Division of Energy, Mineral, and Land Resources
Department of Environmental Quality
[phone]
[e-mail]
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
1

requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to
third parties.
Before printing this email, please consider your budget and the environment.
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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 122.221
General Permit Certificate of Coverage (COC) No.: — AI Lei 1 8
Name of Project: �1 4�/"6 t' 2:10d "J1
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:
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 OrganizationalEntity: S L JAW. L,L-C
*Legally Responsible Person: 40 [� WI 5 C2 S 4 �-L'
Title of Legales gnsi on: /�Z�_ e I on,�,�:i-�-- C c: r-A- ),Lw /
*Signature:
/u/ Ls/.Z i
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 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.