NCC201631_NOT Signed Certification_20210519

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload tea the electronic NOT (Rescission) form_
Then mail the original form to the NC DEMLR Sturnrwater Program at
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, W' Floor
1612 Mail Service Center
Raley, NC 27699-1612
General Permit Certificate of Coverage (COC) No.:
Name of Project: Chi Harm Squam 194039
NCC201631
Per NC General Statute 143-215.6B (i), any poison who knoWngly makes aryfaise siatemeK r+epreseniation,
or certification in any application, record, report, plan, or other docurraent faded or required to be maintained
under this Article or a rule hnplementihg this A,rtide - - - shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,0W)
Under penalty of lava, 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 w th the information contained in this request, and to the best
of my knovAedge and belief, such information is true, complete, and accurate_
Legally Responsible Orgari-aaboml Entity: Jones Lam LaSalle - JLL
*Legally Responsible Person: _ qz" Cersten
Title of Legally ponsi erson: Senior Vice President
*Signature: L r Date: r-111
% Z i
Print Name and Tittle of fined (only if authhorked indAddual signing differs frnxn Legally Responsible Person):
* IMPORTANT N07E. 7leis form must he signed by a resparasible carporate olfrcer Cleat owns or operates the
construction activity, such as a presidents, secretary, bwsurer, or vice president, or a manager that is
authorized in accordance with Part W, Secbm R, Item (6) of the NCGMOOOO permit
For more information on signatory requkements, see Part IV, Section 9 Item (6) of the NCGO10OW permit