NCC191719_NOT Signed Certification_20200508

DocuSign Envelope ID: D1AOB3A1-5EF2-42F9-BA8E-F49B44270DA3
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 form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC191719
Name of Project:
Chick-fil-A Restaurant, Hope Mills, NC
Per NC General Statute 143-215.68 (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:
* Legally Responsible Person:
Title of Lega
Signature:
Chick-fil-A, Inc.
John Mark Wood
e Person: Director, Restaurant Development
te:
5/8/2020 1 2:56 PM EDT
*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 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.

Docu5�"-
ii S E C up E D
Certificate Of Completion
Envelope Id: DlAOB3Al5EF242F9BA8EF49B44270DA3
Status: Completed
Subject: Please DocuSign: Hope Mills FSU #04318 NCG01-eNOT.pdf
Source Envelope:
Document Pages: 1 Signatures: 1
Envelope Originator:
Certificate Pages: 5 Initials: 0
Sally Pierce
AutoNav: Enabled
5200 Buffington Road
Envelopeld Stamping: Enabled
Atlanta, GA 30349
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
[e-mail]
IP Address: 45.30.44.92
Record Tracking
Status: Original
Holder: Sally Pierce
Location: DocuSign
5/8/2020 1:59:28 PM
[e-mail]
Signer Events
Signature
Timestamp
John Mark Wood
[e-mail]
i sg dby:
E "Viewed:
Sent: 5/8/2020 2:01:43 PM
5/8/2020 2:56:14 PM
Securit Level: Email Account Authentication
Y �
D43C6F04CD1442F...
Signed: 5/8/2020 2:56:48 PM
9
(None)
Signature Adoption: Drawn on Device
Using IPAddress: 174.218.16.144
Signed using mobile
Electronic Record and Signature Disclosure:
Accepted: 5/8/2020 2:56:14 PM
ID:397df49f-b875-4fcd-b251-a7843203876d
In Person Signer Events
Signature
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp
Certified Delivery Events
Status
Timestamp
Carbon Copy Events Status Timestamp
Brittany Berube� Sent: 5/8/2020 2:01:44 PM
Brittany. [e-mail]
ED
Paralegal
Chick-fil-A, Inc.
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Mike White Sent: 5/8/2020 2:01:44 PM
[e-mail] ED Viewed: 5/8/2020 2:04:57 PM
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Witness Events Signature Timestamp

Notary Events Signature Timestamp
Envelope Summary Events
Envelope Sent
Certified Delivered
Signing Complete
Completed
Status
Hashed/Encrypted
Security Checked
Security Checked
Security Checked
Timestamps
5/8/2020 2:01:44 PM
5/8/2020 2:56:14 PM
5/8/2020 2:56:48 PM
5/8/2020 2:56:48 PM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure

Electronic Record and Signature Disclosure created on: 11/1/2019 10:56:48 AM
Parties agreed to: John Mark Wood
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, Chick-fil-A, Inc. (we, us or Company) may be required by law to provide to
you certain written notices or disclosures. Described below are the terms and conditions for
providing to you such notices and disclosures electronically through the DocuSign system.
Please read the information below carefully and thoroughly, and if you can access this
information electronically to your satisfaction and agree to this Electronic Record and Signature
Disclosure (ERSD), please confirm your agreement by selecting the check -box next to `I agree to
use electronic records and signatures' before clicking `CONTINUE' within the DocuSign
system.
Getting paper copies
At any time, you may request from us a paper copy of any record provided or made available
electronically to you by us. You will have the ability to download and print documents we send
to you through the DocuSign system during and immediately after the signing session and, if you
elect to create a DocuSign account, you may access the documents for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per -page fee. You may request delivery of such paper copies from us by following the
procedure described below.
Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to
receive required notices and consents electronically from us or to sign electronically documents
from us.
All notices and disclosures will be sent to you electronically

Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.
How to contact Chick-fil-A, Inc.:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: [e-mail]
To advise Chick-fil-A, Inc. of your new email address
To let us know of a change in your email address where we should send notices and disclosures
electronically to you, you must send an email message to us
at [e-mail] and in the body of such request you must state: your
previous email address, your new email address. We do not require any other information from
you to change your email address.
If you created a DocuSign account, you may update it with your new email address through your
account preferences.
To request paper copies from Chick-fil-A, Inc.
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an email to [e-mail] and
in the body of such request you must state your email address, full name, mailing address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with Chick-fil-A, Inc.
To inform us that you no longer wish to receive future notices and disclosures in electronic
format you may:

i. decline to sign a document from within your signing session, and on the subsequent page,
select the check -box indicating you wish to withdraw your consent, or you may;
ii. send us an email to [e-mail] and in the body of such request you
must state your email, full name, mailing address, and telephone number. We do not need any
other information from you to withdraw consent.. The consequences of your withdrawing
consent for online documents will be that transactions may take a longer time to process..
Required hardware and software
The minimum system requirements for using the DocuSign system may change over time. The
current system requirements are found here: hitps://sU]2ort.docusign.com/guides/signer-guide-
si fining -system -requirements.
Acknowledging your access and consent to receive and sign documents electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please confirm that you have
read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for
your future reference and access; or (ii) that you are able to email this ERSD to an email address
where you will be able to print on paper or save it for your future reference and access. Further,
if you consent to receiving notices and disclosures exclusively in electronic format as described
herein, then select the check -box next to `I agree to use electronic records and signatures' before
clicking `CONTINUE' within the DocuSign system.
By selecting the check -box next to `I agree to use electronic records and signatures', you confirm
that:
You can access and read this Electronic Record and Signature Disclosure; and
You can print on paper this Electronic Record and Signature Disclosure, or save or send
this Electronic Record and Disclosure to a location where you can print it, for future
reference and access; and
Until or unless you notify Chick-fil-A, Inc. as described above, you consent to receive
exclusively through electronic means all notices, disclosures, authorizations,
acknowledgements, and other documents that are required to be provided or made
available to you by Chick-fil-A, Inc. during the course of your relationship with Chick-
fil-A, Inc..