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HomeMy WebLinkAboutNCC221710_NOT Signed Certification_20240617 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,6'h 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.: NCC221710 Name of Project: 4 Middlebury Ct Per NC General Statute 143-215.66(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): Latitude Builders LLC *Legally Responsible Person(must match eNOT): Tyler Cook *Title of Legally Responsible Person: Owner/GC Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person: *Signature: Date: 06/17/2024 *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.