NCC232677_NOT Signed Certification_20240403

NCGO1 Notice of Termination 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 Gt1=VIFWEi)AND APPROVED.
THE FORM YOU MAIL. MUST LIE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR:122.72]
General Permit Certificate of Coverage (COC) No.: NCC232677
Name of Project: Scott Hill Reserve-Lots 7-9& 15
Per NC Genera!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
Member Manager
Title of Legally Responsible Person:
*Signature: �" ""' Date:
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 5,Item(6)of the NCG010000 permit.
1