NCC205795_NOT Signed Certification_20210806

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,6" Floor
1612 Mail Service Center
Raleigh,NC 27699-1612
General Permit Certificate of Coverage (COC) No.: MOORS-2021-046/NCC205795
Name of Project: Winds Way Farm lots 97,98,99,101,102,111
Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement representation,
or certification in any application, record, report,plan, or other document filed led 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:
d I, as an authorized representative, hereby request rescission of coverage underthe 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: Caviness Land Development
* Legally Responsible Person: Watson G Caviness
Title of Legally Responsible Person: President
Signatur : Date: 8/6/2021
* 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 NCG010000 permit.