NCC232107_NOT Supporting Documents (2)_20240716

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 (COC) No.: NCC232107
Name of Project: Rolesville Crossing
Per NC General Statute 143-215.6E(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): Hopper Communities, Inc.
*Legally Responsible Person(must match eNOT): Bart Hopper
*Title of Legally Responsible Person: President
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: , ,„,,,,,,,,t4_, Date:
1It � (I IA
*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 8, Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B,Item(6)of the NCG010000 permit.

fact in a rulemaking proceeding or contested case under this Article:or who falsifies,tampers with,or knowingly renders inaccurate any recording
or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars(S10,000).
* 0 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.
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 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6)of that permit.
Signature* Q.a.euver,..____
Type Name* Bart Harper
Title* eg etc-tA
Organization* Hopper Communities, Inc.
Date* Date will be captured on form submission
Email for [e-mail]
Confirmation*
Contact Telephone* 7046493097
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link)to The Stormwater
Program at the address on the form for the application to fulfill federal requirements.You must also upload a copy of that
completed below:
NOT Certification Upload
Form* Must be PDF Format