NCC216653_NOT Signed Certification_20240116

NCGO1 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 122.22]
General Permit Certificate of Coverage (COC) No.: NCC216653
Name of Project: Kerners Mill Creek Greenway
Per NC General Statute 143-215.66(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(must match eNOT): Town of Kernersville
*Legally Responsible Person (must match eNOT): Doran C. Maltba
*Title of Legally Responsible Person: Director of Public Services
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 12/18/2023
* 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 6, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section 6, Item(6)of the NCG010000 permit.

Notice of Termination (NOT) Request
Department ;onme„ta, NPDES Stir mater 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Coverage (COC)will be rescinded.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 NCC216653
Coverage (COC) Enter the Certificate of Coverage Number(Use capital letters)
No.*
Information associated with this permit:
Project Name Kerners Mill Creek Greenway
Address Southern Street, Kernersville, NC
County Forsyth
Latitude 36.1151
Longitude -80.0860
Permittee Listed Town of Kernersville
Legally Responsible Curtis Swisher
Individual
E&SC Plan ID FORSY-2022-011
Original NOI 74054
Tracking No.*
Date COC Issued* 12/01/2021
Prior Rescission
Date This field will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:

Reason for Ce) Project Closed-Out
Termination of (,) Sale (Another Owner/Operator obtained new COC)
Coverage* C) Mistake or Invalid Coverage
0 Other
Additional More information about the basis of this request. 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 (E&SC) Plan.
Erosion Control Plan 10/12/2023
Close-out Date*
Erosion Control Plan Upload
Close-out FORSY-2022-011 Kerners Mill Creek ... 30.49KB X
Documentation*
Must be PDF format
North Carolina General Statute 143-215.6B'(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).
[_j 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.
*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* Sign
Type Name*

Title*
Organization*
Date* Date will be captured on form submission
Email for
Confirmation*
Contact Telephone*
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link)
(https://www.deq.nc.gov/energy-mineral-and-land-resources/stormwater/npdes-general-permits/ncg01-enot-
certification-form/download) 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 � Upload
Form Mustbe PDF Forma'
Additional Email [e-mail]
(Optional)
Save as Draft