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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 I3E COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) )40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: NCC233485
Name of Project: Windy Ridge-Lots 14,22,24
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:
A&G Residential LLC
*Legally Responsible Person: Jamie Godwin
Title of Legally Responsible Person: Member Manager
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*Signature: r _r.� .....�.__......._......_ Date:
5Jniiy
Print Name and Title of Signed (only if authorized individual signing 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.
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