NCC200468_NOT Signed Certification_20210310

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, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC200468
Name of Project. Lot #3 Finger Lakes Drive
Per NC General Statute 143-215.68 (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 familiarwith 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: JlVloffat Properties, LLC
*Legally Responsible Person: Craig T. Moffat
Title of Legally Responsible Person
*Signature:
Member
Date: • Z
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 1V, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part 1V, Section e, Item (6) of the NCGO10000 permit.