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Home My WebLink About2024-111-E-Planning Dept-Christopher Sandt -need Bonnie’s hard signature on an NCDEQ notice of termination not form so that we may formally close out the Lake OrangeRevised 01/24 1 ORANGE COUNTY—INTERNAL USE ONLY ______________________________________________________________________________ Finance Information Vendor Name: Christopher Sandt Vendor Contact Person: Christopher Sandt Phone: 919-245-2583 Address: 131 W. Margaret Lane, 2nd Floor City Hillsborough State: NC Zip: 27278 Department: Planning Amount: $0 Purpose: need Bonnie’s hard signature on an NCDEQ “Notice of Termination” (NOT) form so that we may formally close out the Lake Orange Erosion Control Barrier Replacement Project Budget Code(s): N/A Vendor # N/A Vendor Status with NCSOS: N/A Vendor is a BOCC consultant: Yes No Contract Details Contract Type: New Amendment (Original Contract: ) (Most Recent Amendment ) Effective Date End Date Notice Date (Notice Purpose ) Award Approved by Board (Agenda Date: ); Made or Administered by Signature Authority - BOCC Express Delegation (Agenda Date: ) - Policy 9.4: Under $5,000; Service Under $90,000; Construction Under $250,000 - Budget Policy Section XV (Capital Improvement Project: ) Bidding Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# ) Department Affirmation This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement. This agreement is approved as to technical form and content. Services related to this agreement have already begun or been completed. Description of the nature of the emergency condition that was addressed: Department Director’s Signature ________________________________________ Date: ________ Information Technologies This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Inapplicable because no hardware/software purchases or related services Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Received for record retention: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: 45F63519-E597-49A4-A85A-BE797784EB5F 2/14/2024 2/19/2024 2/19/2024 2/19/2024 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 122.22] General Permit Certificate of Coverage (COC) No.: ___________________________________ Name of Project: ______________________________________________________________ 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 (must match eNOT):_________________________________________ *Legally Responsible Person (must match eNOT):_____________________________________________________ *Title of Legally Responsible Person:_______________________________________________________________ Print Name & Title of Signed if Authorized Individual 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 NCG010000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit. *Signature: _____________________________________________________________Date: _______________ NCC220409 Lake Orange CIP - Project 1 - Erosion Control Barrier Replacement (BASE BID ONLY Orange County, North Carolina Bonnie Hammersley County Manager DocuSign Envelope ID: 45F63519-E597-49A4-A85A-BE797784EB5F 2/19/2024