HomeMy WebLinkAboutNCC192944_NOT Signed Certification_20240209 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 (CDC) No.: NCC192944
Name of Project: The Pines
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): Smith Douglas Homes
*Legally Responsible Person(must match eNOT): Ron Willing
*Title of Legally Responsible Person: Land Development Mgr.
Print Name &Title of Signed if Authorized Individual Differs from Legally Responsible Person:
John J Brunner, VP Land Development/Smith Douglas Homes
*Signature: Ql! Date:
*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 8, Item(6)of the NCG010000 permit.
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