NCC202470_NOT Signed Certification_20210609

CG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO OT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Pertnit Certificate of Coverage (COC) No.:
Name of Project:
NCC202470
969 Sandavis Rd. Southern Pines, NC 28387
Per NC Gener 1 Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification i 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 penalt4 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 Respohsible Organizational Entity:
*Legally Respohsible Person:
The Ascot Corporation, LLC
Colin Webster
Title of Legalljr Responsible Person:
*Signature:
Manager
Date: 6/1 /21
Print Name a d Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* owns or
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that o operates the
construction Fctivity, such as a president, secretary, treasurer, or vice president, or a manager that is authorized in
accordance With Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.