NCC200627_NOT Signed Certification_20210210

NCGO1 Noticen of Term inatIon jNOT) e-rtilfkation Form
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RaIelgfi, NC 27699-1612
General Permit Certificate of Coverage (COC) Flo-.
Name of Project -
Chatham Park DTATRRF Potable Water L'_ne lxtenBiorr
Per NCt3enerofStmmte 143-215.6D (r), any person who krrawln&makes artyr false statement, representatPorr,
or cerrJf=tfOn in any appfrcafiorr, reCard, report, plan, or other docum entfiled -or requ rre d to be mornwirted
under rhos Article or rare implemer;ting this Arncle _ . -shall by gL ity of a Crass 2 mi!Wemearror w hr rh may �
include more not to exceed ren thousand diWars ( 10rl �.
Under penaity of law, F certify that:
1, as a n authnrim. rl representative, hereby request rescission of coverage under tine NPDES
Stormwater Permit for the subject facility- I am familiar with the information contained in tlla5 -
reque-st, and to the best of my knowIeda-e and belief, such information is true, complete, and
accurate. A
Legally RespDnsibleorganizational EWtV. Chatham Park TnvO Lori LLC
*LLIIgally Responsible Person:
Tim SmitK
Title of L-egally Responsihle Person:
Cw-)er ;{ Manager
*Signature- < -- — -
Date:
Print Name and Title of Signer (.only if authorized individual signing differs from Legally ResporrsiWe
Rob_J n R. c,5e, Designated Agent
*IMPURTANTA10TE. This form must be si'graed by a responsible carpomte officer that owns or operates the
.CDnStruation activl% slrC'h os j7 pr,*Srder?t, Secretory, trea5u(er, ar Vrce president, Or o Mil na98F that IiS
oVthorized in laic rdarice with pert lV, Section B, !team ( � of the NCGO1OWO permit
FOr rrrare irtformarrlon on signat+ary requirements, see Parl �Vr Section & item �6)1 the NC OI0000 permit.