NCC204646_NOT Signed Certification_20210411

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, 61" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.:
Name of Project:
Skylark Acres Subdivision
NCC204646
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 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:
*Legally Responsible Person
Title of Legally Responsible Person
*Signature: Robert Weidl(Mar23,202111:02EDT)
Weidl Properties, LLC
Robert Weidl
Member -Manager
Date: M a r 23, 2021
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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.
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NCG01-eNOT-Skylark Acres
Final Audit Report 2021-03-23
Created:
2021-03-23
By:
Alex Carter ([e-mail])
Status:
Signed
Transaction ID:
CBJCHBCAABAA1AFiLMGuKbjY6WAmnU8jdSmuSuCBQh4H
"NCG01-eNOT-Skylark Acres" History
Document created by Alex Carter ([e-mail])
2021-03-23 - 2:11:22 PM GMT- IP address: 71.76.213.40
Document emailed to Robert Weidl ([e-mail]) for signature
2021-03-23 - 2:11:45 PM GMT
Email viewed by Robert Weidl ([e-mail])
2021-03-23 - 2:42:14 PM GMT- IP address: 174.245.113.247
z4[� Document e-signed by Robert Weidl ([e-mail])
Signature Date: 2021-03-23 - 3:02:17 PM GMT - Time Source: server- IP address: 174.245.113.247
Agreement completed.
2021-03-23 - 3:02:17 PM GMT
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