NCC203602_NOT Closeout Documents_20240404

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 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
General Permit Certificate of Coverage (COC) No.: 1-4 C(; 2 03 co o 2-
Name of Project: (t 4 Did PtrA)be C-ft� Pke-K 12-tµ 0 VA lOt-s
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 enalty 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: (A/U Cte.L BUit-C1 Coo P-t-'`i.
* Legally Responsible Person: +Q-- VJ t 5 T )' • C (l 4't3 •
Title of Legally Responsible Person: t �(ZOate�" V14�A-li -• _
Signature: e,.... Date: l l O ZLt,
* 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 NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCG010000 permit.

Sedimentation/Construction Stormwater Inspection Report
North Carolina Department of Environmental Quality
Land Resources: 610 East Center Avenue, Suite 301, Mooresville,NC 28115 [phone]
County: Mecklenburg Project: Independence Park River basin: Catawba
Person financially responsible:Mecklenburg County-Karen Weston-Chien,Project Manager Project#: MECKL-2021-004
Address: 3205 Freedom Drive,Suite 101,600 East 4th Street, 1 lth Floor,Charlotte,NC 28208
1. Project Location: 300 Hawthorne Lane,Charlotte
Pictures: No
2. Weather and soil conditions: Sunny,Workable Soils Initial inspection: No
3. Is site currently under notice of violation? No
4. Is the site in compliance with S.P.C.A. and rules? Yes If no,check violations below:
5. Violations:
6. Is the site in compliance with NPDES Permit NCG010000 Construction Stormwater requirements? Yes
Describe:
7. Has sedimentation damage occurred since last inspection? No If Yes,where? (check all that apply)
Degree of damage:
8. Contact made with(name): No One Onsite Title:
Inspection report: Sent Report Date given/sent: March 25,2024
9. Corrective action needed:
10. Comments: Overall the site has sufficient permanent ground cover to restrain erosion,however there are
some bare areas that need to be stabilized surrounding light poles. No additional
self-monitoring or self-inspections are required.Project is in compliance and released under
the SPCA.Termination of coverage under the NPDES General Stormwater Permit for
Construction Activities(NCG01)must be requested by the permittee via a Notice of
Termination(NOT)unless permit approval date was prior to April 2019.
The NOT is available at:https://edocs.deq.nc.gov/Forms/NCG01-Termination.Please note
that this correspondence must be uploaded as part of completing the NOT process.
Reported by: Jeffrey Chandler Others present:
Date of inspection: March 20,2024 Time arriving on site: 9:30 AM Time leaving site: 9:45 AM
cc: