NCC204891_NOT Signed Certification_20230216

NCGa1 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'' 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 ORIGINAi. SIGNATURE (NUT DIGITAL) 140 CFR 122.221
General Permit Certificate of Coverage (COC) No.:
Name of Project:
NCC204891
Meadows of Banks Subdivision, Phase 2, Lot 31
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 far
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: Ken Harvey Hornes, LLC
*Legally Responsible Person: Andy Beaird
Title of teizalWR2=DMIbWPerson-----.—.Member Manager
*Signature:
Date: 02/16/2023
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
accordonce with Part IV, Section B, Item (6) of the IVCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

ON
WAKEj�^
VA V KE Wake County Sediment and Erosion Control Section, Water quality Division
COUNTY 336 Fayetteville Street - PO Box 550 - Raleigh, NC 27602
"`1"`-''`''1"' Phone:[phone]; Fax:[phone]
CERTIFICATE OF COMPLETION
SEDIMENTATION AND EROSION CONTROL
PROJECT: Meadows of Banks PH2 Lot 31
LOCATION: 5308 Banks Rose Way, Raleigh NC
S&E PERMIT NUMBER: SEC-045902-2020
DATE: 7/9/21
This document certifies that the land disturbance permit for the above
reference project is complete; 1) all conditions of the approved land
disturbance permit are met; 2) all disturbed areas are stabilized with
permanent ground cover, permanent armor or impervious surface; 3) all
proposed roads, utilities, permanent erosion control devices and other
infrastructure have been installed according to approved plans; 4) all
requirements of the approved stormwater plan are met; and 5) all
temporary sediment and erosion control devices have been removed or
converted to permanent stormwater devices according to the approved
stormwater plan.
As of the above date, the Water Quality Division of Wane County
Department of Environmental Services, deems this project to be complete
and the Land Disturbance (Grading) permit closed. This document also
serves as a notice of termination of the NPDES Permit (NCG01). Continued
self monitoring of the project for NPOES compliance is no longer required.
Environmental Consultant: Brian Wall
Phone: [phone]