NCC202717_NOT Signed Certification_20210609

N�G01 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, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DON T MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM Y U MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: NCC202717
Name of Project: 975 Sandavis Rd. Southern Pines, NC 28387
Per NC General tatute 143-215.6E (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: The Ascot Corporation, LLC
*Legally Responsible Person:
Colin Webster
Title of Legally &espQnsible Person
*Signature:
Manager
Date: 6/1 /21
Print Name andlTitle of Signed (only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT NQTE: 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 wito Part iv-, Section S, item (a) of the NCG010000 permit.
For more infornation on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.