NCC214284_NOT Signed Certification_20230321

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, 61h 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.:
Name of Project: ���YA1tb1 R-C�jla�vlC�'
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: TTGj�U i
*Legally Responsible Person: Iv l L ��if, T I S�Oy-
Title of Legally Responsible P,prson: C'v- ma, \C{atjy
*Signature:
Date:
Print Name and Title of SigWed (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 B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

°0 NA SOIL EROSION and SEDIMENTATION CONTROL
14 a a.� Lincoln County Natural Resources Department
Ru,R `Cs 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
Final Inspection
Project ID#/ Name: O'Brien Residence: Wallace Ln. (21-OTH-07) Date: 3/14/23
Final Inspection Date: 318/23
To Mr. Mike Testa,
On March 8, 2023 personnel of the Lincoln County Natural Resources Department inspected the
above —named project located in Lincoln County, NC. This inspection was performed to determine
compliance with the Lincoln County Soil Erosion and Sedimentation Control Ordinance and the
North Carolina Sedimentation Pollution Control Act of 1973. The inspection revealed a land -
disturbing activity of approximately 1.9 acres has been completed. With this final approval, you
are granted the option to remove any or all of the temporary erosion control measures on the tract
described above. If at any time the land -disturbing activities are to resume for any reason you are
required to notify the Lincoln County Natural Resources Department for approval before the land -
disturbing activity begins.
It is our understanding that JS Testa, LLC was responsible for this land -disturbing activity. The
purpose of this letter is to inform you that this activity was found to be in compliance with the
Lincoln County Soil Erosion and Sedimentation Control Ordinance and the North Carolina
Sedimentation Pollution Control Act of 1973 and the site has been stabilized.
Please visit https://deg.nc.gov/about/divisions/energy-mineral-and-land-
resources/stormwaterlstormwater-program/npdes-construction-program to file for your e-
NOT (electronic Notice of Termination). This will end coverage of your NCG01 Permit and
completely satisfy all erosion control related requirements.
It has been a pleasure working with you. If you, at any time, have questions regarding this letter
or other questions regarding any future projects, please feel free to contact the Lincoln County
Natural Resources Department immediately at: 704-736-8501.
S' ere y,
ielle 7. ?y&ui9 OP SC
Erosion and Sedimentation Control Administrator
Lincoln County Soil and Water Conservation District
Natural Resources. Soil Erosion and Sedimentation Control
Office: [phone]
Fax: [phone]
drudisill(a.)lincolncounty.org

3/15/23, 11:16 AM
New Submission
e,��D_ E Q Notice of Ternnination (Nun Request - NPDES
NOnT
Stormwater Permit for Construction Activities
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 NCC214284
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name O'Brien Residence
Address 7659 Wallace Lane, Denver, NC
County Lincoln
Latitude 35.4969
Longitude -80.9988
Permittee Listed J.S. Testa, LLC
Legally Responsible Mike Testa
Individual
E&SC Plan ID 21 -OTH-07
Original NOI Tracking 59786
No.
Date COC Issued* 07/27/2021
Prior Rescission Date
This field will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:
Reason for # Project Closed -Out
Termination of 0 Sale (Another Owner/Operator obtained new COC)
Coverage 0 Mistake or Invalid Coverage
0 Other
Additional More information about the basis of this request, if needed.
Explanation
hops://edocs.deq.nc.gov/Forms/ncg01-termination . 1/3

3/15/23, 11:16 AM
New Submission
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 (E&SC) Plan.
Erosion Control Plan 3/8/2023
Close-out Date*
Erosion Control Plan Upload
Close-out * doc05708620230315111530.pdf (blob:https:;ledoc... 443.88KB X
Documentation
Must be PDF format
North Carolina General Statute 143-215.613 (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 r lemaking 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 net to exceed ten thousand dollars ($10:000).
® 1, 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature* x
3 i1-d
3
Type Name* Michael J Testa
Title* Member Manager
Organization * J.S. Testa, LLC
Date * Date will be captured on form submission
Email for [e-mail]
Confirmation *
Contact Telephone* 704-892-2995
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link)
(https://files.nc.gov/ncdeq/Energy°/a20Mineral%20and%2OLand%2OResources/Stormwater/NPDES%2OGeneral
eNOT-Certification-Form-20210514-DEMLR-SW.pdf) 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:
`.i
https://edocs.deq.nc.gov/Forms/ncg01-termination . 2/3