NCC192029_NOT Closeout Documents_20231207

NCGO1 Notice of
Termination (NOT) Certification Form
Directions:
Print this
form,complete,scan and upload to the electronic
NOT er(Rescission)Program fotm
m to the NC
Then,mail the original signe r&Land ResouDEMLR rces Stormwater Program
Division of Energy,Mineral
512 N.Salisbury Street,6'h Floor
1612 Mail Service Center
Raleigh,NC 27699-1612
N ' 'AND
AP)ROt40 ED.122.22]
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST I HAS BEEN dAL SIGNATURE REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL
General Permit Certificate of Coverage (COC) No..
gg&T Leadership Institute Parking Lot
Name of Project:
any person who knowingly makes any false statement,representation,or
Per NC General ny application,
143-215.6B(rd� report,plan, or other document filed or requied to b mmaa include a fitained ne e noer t
Articlecert
ation inl anyimplementing
hisrec p a Class 2 misdemeanor
or a rule impiemenot'lnp s��10,000), .shall be guilty of
to exceed ten thousand d
Under penalty of law,I certify that:
herebyrequest rescission of coverage under the dN oD h best of Stormwatermy Permit for
the u authorized representative,
ge
subject facility. I am familiar etcompieter and accuratemation ined in this request,an
and belief,such information is true, Branch Bank &Trust
Legally Responsible Organizational Entity(must match O'HaraNOT
*Legally Responsible Person(must match eNOT): Daniel
Responsible Person: Senior Manager
*Title of Legally onsible Person:
Print Name&Title of Signed if Authorized Individual Differs ers from Legally Resp
III15f1Z3
Date:
*Signature: �`� Xielli-4&-
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity,suc
h as a president,secretary, treasurer, or vice president,or a manager that is authorized in
the NCG010000 permit.
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