NCC233076_NOT Signed Certification_20240924

Notice of Termination (NOT) Certification
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 T is FORM UNTIL YOUR NOT REQ.UFST HAS MEN RFViEWk R AND APPROVED.
rHE FORM YOU 3IA/L MUST:BE COMPLETED' f.1f'I.AN CgfEciNklStu t Utiii'( T Oid040:446t0A:122,221
General Permit Certificate of Coverage (COC) No.: NCC233076
Name of Project: Carolina Crossing,Phase One-Lots 23,24,30,31,44&53 and Lot 13
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: A&GResidential LLC
*Legally Responsible Person: Jamie Godwin
Title of Legally Responsible Person: Member Manager
*Signature: —' Date: `felt 2v
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.