NCC232436_NOT Signed Certification_20240910

Notice 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 °�s‘r r�WWi N AND APPROVED.
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General Permit Certificate of Coverage (COC) No.: NCC232436
Name of Project:
Braxton Village,Phase 3 Lots 192,200,201,213,214,216&219
Per NC General Statute 143-215.6E(I), any person who knowingly makes any false statement, representation, or
certification in anyapplication,record,report,plan, or other documentfiled or required to be maintained under this
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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: Janie Godwin
Title of Legally Responsible Person: Member Manager
*Signature: Date: ) 4/0
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 8, 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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