NCC203070_NOT Signed Certification_20210728

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 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 NOT 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 Permit Certificate of Coverage (COC) No.: NCC203070
Name of Project: 5309 Pine Drive
Per NC General Statute 14.3-215.6B (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 o 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 Persow�
Title of Legally Respo s' a Pers
*Signature:
it
Print NamA.and Title of Signed (only if out
Schumacher Homes of NC
er)#rat Manader
Date: �
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 B, item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part iV, Section B, Item (6) of the NCGO10000 permit.

WAKE
COUNTY
Case Number:
Inspection Date:
Inspector:
Job Address:
Contact Type
Applicant
Checklist Item
SEC-038865-2020
03/10/2021
Andrew Lake
5309 Pine Dr
Raleigh, 27606
Company Name
Schumacher Homes of NC Inc
Case Module: Permit Management
Inspection Status: Passed
Inspection Type: WM - Certificate of Completion
Parcel Number: 0781066967
Name
Jay Guido
Results Comments
March 10, 2021 Report Text Library: Municipality_Page_Footer Page 1 of i