NCC221277_NOT Signed Certification_20231003

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.: NCC221277
Name of Project: Lewisville Post Office
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(must match eNOT): Maple Tree Investments
*Legally Responsible Person (must match eNOT): Todd Conley _
*Title of Legally Responsible Person: Owner
Print Name &Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 10 / 03 / 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 8, Item (6)of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6)of the NCG010000 permit.
Doc ID: 0d6db59db293730ab32f012aa9487a9c9b31de62

Dropbox Sign Audit trail
Title NCGO1 eNOT Certification Form - Lewisville Post Office
File name NCG01-eNOT-Certif...0601-DEMLR-SW.pdf
Document ID 0d6db59db293730ab32f012aa9487a9c9b31de62
Audit trail date format MM / DD/YYYY
Status Signed
Document History
09/25/2023 Sent for signature to Todd Conley
SENT 17:41:21 UTC ([e-mail])from
[e-mail]
IP: 216.237.202.42
09/25/2023 Viewed by Todd Conley([e-mail])
VIEWED 17:45:50 UTC IP: 174.228.161.141
10/03/2023 Signed by Todd Conley([e-mail])
SIGNED 15:37:21 UTC IP: 99.194.135.54
�✓ 10/03/2023 The document has been completed.
COMPLETED 15:37:21 UTC
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