NCC191188_NOT Signed Certification_20200511

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original 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
General Permit Certificate of Coverage (COC) No.: NCC191188
Name of Project: Mt. Airy, NC Dollar General
Per NC General 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:
X I, as an authorized representative, hereby request rescission of coverage underthe NPDFS
Stormwater Permitforthe subject facility. I am familiarwith the information contained in this
request, and to the best of my knowledge and belief, such information is true, complete, and
accu rate.
Legally Responsible Organizational Entity: Teramore Construction
* Legally Responsible Person: Senior Vice President
Title of Legally Responsible Person:
Signature:
a,
*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 (5) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.